Healthcare Provider Details

I. General information

NPI: 1104357516
Provider Name (Legal Business Name): ALEXANDER LEOPOLDO FORMOSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 N KENDALL DR
MIAMI FL
33176-2118
US

IV. Provider business mailing address

150 ISLA DORADA BLVD
CORAL GABLES FL
33143-6549
US

V. Phone/Fax

Practice location:
  • Phone: 786-596-1960
  • Fax:
Mailing address:
  • Phone: 305-510-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number142271
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME142271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: