Basic Information
Provider Information | |||||||||
NPI: | 1093135774 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | QUINONES | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | JORGE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3170 KETTERING BLVD | ||||||||
Address2: | BUILDING B 3RD FLOOR | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454391924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9379913188 | ||||||||
FaxNumber: | 9372239811 | ||||||||
Practice Location | |||||||||
Address1: | 30 E APPLE ST STE 2200 | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454092939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372082091 | ||||||||
FaxNumber: | 9372084007 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2014 | ||||||||
LastUpdateDate: | 10/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2019011449 | MO | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XS0117X | 2019011449 | MO | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | 35.139659 | OH | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | 35.139659 | OH | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0415165 | 05 | OH |   | MEDICAID |