Provider Demographics
NPI:1649266925
Name:ALFONSO, JESUS ROBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:JESUS
Middle Name:ROBERTO
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-7210
Mailing Address - Country:US
Mailing Address - Phone:201-330-8747
Mailing Address - Fax:201-330-8947
Practice Address - Street 1:4800 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-7210
Practice Address - Country:US
Practice Address - Phone:201-330-8747
Practice Address - Fax:201-330-8947
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05064100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3410307Medicaid
NJ560910P4PMedicare PIN
NJ3410307Medicaid