Healthcare Provider Details

I. General information

NPI: 1992864359
Provider Name (Legal Business Name): LUIS ALONSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 BARNES ROAD SUITE 102
WALLINGFORD CT
06492
US

IV. Provider business mailing address

1062 BARNES ROAD SUITE 102
WALLINGFORD CT
06492
US

V. Phone/Fax

Practice location:
  • Phone: 203-294-6328
  • Fax: 203-294-6346
Mailing address:
  • Phone: 203-294-6328
  • Fax: 203-294-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number016387
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number016387
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: