Provider Demographics
NPI:1528324613
Name:ALONSO, KATIE CLEARY (MD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:CLEARY
Last Name:ALONSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-2847
Practice Address - Street 1:2392 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996
Practice Address - Country:US
Practice Address - Phone:772-223-4978
Practice Address - Fax:772-223-2847
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135502207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7FQC7OtherFLORIDA BLUE
FL100374400Medicaid