Healthcare Provider Details

I. General information

NPI: 1215432901
Provider Name (Legal Business Name): JASON QUALLEY MD, CCP,LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 CRYSTAL BEACH DR STE 200
DESTIN FL
32541-3588
US

IV. Provider business mailing address

155 CRYSTAL BEACH DR STE 200
DESTIN FL
32541-3588
US

V. Phone/Fax

Practice location:
  • Phone: 850-353-2055
  • Fax: 855-344-6080
Mailing address:
  • Phone: 850-353-2055
  • Fax: 855-344-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME165604
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME165604
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number613883
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: