Healthcare Provider Details

I. General information

NPI: 1518062249
Provider Name (Legal Business Name): LEONARDO LAZARO ALONSO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8761 PERIMETER PARK BLVD STE 106
JACKSONVILLE FL
32216-6397
US

IV. Provider business mailing address

831 CHICOPIT LN
JACKSONVILLE FL
32225-4913
US

V. Phone/Fax

Practice location:
  • Phone: 904-641-6628
  • Fax:
Mailing address:
  • Phone: 904-221-8961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS-6584
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3206
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: