Provider Demographics
NPI:1699308403
Name:ALFONZO DIAZ, ANTONIO ANDRES
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:ANDRES
Last Name:ALFONZO DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-4704
Mailing Address - Country:US
Mailing Address - Phone:413-846-0445
Mailing Address - Fax:
Practice Address - Street 1:80 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-4704
Practice Address - Country:US
Practice Address - Phone:413-846-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA997303OtherNETWORK HEALTH
MA1134107113OtherMBHP
MA1134107113OtherFALLON
MA1134107113Medicaid
MA1134107113OtherNHP
MA1134107113OtherBEACON
MA042622756OtherCCA
MA12529OtherHNE
MA71756OtherTUFTS
MAY10086OtherMEDICARE