Healthcare Provider Details

I. General information

NPI: 1962815100
Provider Name (Legal Business Name): MICHAEL QUACINELLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 FOURTH AVE STE 630
SAN DIEGO CA
92103-2118
US

IV. Provider business mailing address

4060 FOURTH AVE STE 630
SAN DIEGO CA
92103-2118
US

V. Phone/Fax

Practice location:
  • Phone: 619-299-3950
  • Fax:
Mailing address:
  • Phone: 619-299-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number5113
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number20A14499
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20A14499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: