Provider Demographics
NPI:1962961151
Name:KONG IBANEZ, ALEXANDER ANDRE (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ANDRE
Last Name:KONG IBANEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 UNDERWOOD ST # MP80
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:321-841-3581
Mailing Address - Fax:321-841-4085
Practice Address - Street 1:52 UNDERWOOD ST # MP80
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:321-841-3581
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME155321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114749000Medicaid