Healthcare Provider Details

I. General information

NPI: 1710041314
Provider Name (Legal Business Name): ALFONSO PACHECO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 560 GUM SPRING RD WINN CORRECTIONAL CENTER
WINNFIELD LA
71438
US

IV. Provider business mailing address

502 SINGER
PINEVILLE LA
71360
US

V. Phone/Fax

Practice location:
  • Phone: 318-628-3971
  • Fax:
Mailing address:
  • Phone: 318-443-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number013897
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: