Basic Information
| Provider Information | |||||||||
| NPI: | 1912939398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUILLEN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUILLEN | ||||||||
| OtherFirstName: | DAVID | ||||||||
| OtherMiddleName: | MICHAEL | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 918025 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328918025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523926771 | ||||||||
| FaxNumber: | 3523924549 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 W NEWBERRY RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326056611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523315310 | ||||||||
| FaxNumber: | 3523320482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME77291 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 255046600 | 05 | FL | MEDICAID |