Healthcare Provider Details

I. General information

NPI: 1427055532
Provider Name (Legal Business Name): ALFONSO MIRELES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 WEST STATE ROAD 434, SUITE 101 PEDIATRIC & ADOLESCENT MED OF SEMINOLE, IN ASSOC WITH NEMOURS
LONGWOOD FL
32750-4952
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 407-830-5437
  • Fax: 407-830-4907
Mailing address:
  • Phone: 302-651-4488
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME54968
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME54968
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: