Healthcare Provider Details

I. General information

NPI: 1700204583
Provider Name (Legal Business Name): QUANTEL VALDEZZEL ROLLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 W JEFFERSON BLVD STE 306
FORT WAYNE IN
46804-4128
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-3610
  • Fax: 260-458-3611
Mailing address:
  • Phone: 260-479-3514
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036151291
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number01092692A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: