Basic Information
| Provider Information | |||||||||
| NPI: | 1902169626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUIROGA | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | JEANETTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3046 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193550746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104919400 | ||||||||
| FaxNumber: | 2104913550 | ||||||||
| Practice Location | |||||||||
| Address1: | 17720 CORPORATE WOODS DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782593500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104919400 | ||||||||
| FaxNumber: | 2104913550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | Q7262 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 358863401 | 05 | TX | MEDICAID |