Healthcare Provider Details

I. General information

NPI: 1720020092
Provider Name (Legal Business Name): QUIRINO LIM PUA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 US HIGHWAY 431
BOAZ AL
35957-5908
US

IV. Provider business mailing address

PO BOX 1164
DALTON GA
30722-1164
US

V. Phone/Fax

Practice location:
  • Phone: 258-840-3480
  • Fax: 256-840-3626
Mailing address:
  • Phone: 706-271-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number9242
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number9242
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: