Healthcare Provider Details

I. General information

NPI: 1225085590
Provider Name (Legal Business Name): ALFONSO E URDANETA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 SOUTH GRAND AVENUE
NASHVILLE IL
62263-1534
US

IV. Provider business mailing address

3416 HOTZE ROAD
SALEM IL
62881-6616
US

V. Phone/Fax

Practice location:
  • Phone: 618-327-2225
  • Fax: 618-327-2229
Mailing address:
  • Phone: 618-548-1185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036047128
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036047128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: