Healthcare Provider Details

I. General information

NPI: 1053502435
Provider Name (Legal Business Name): RICARDO MANUEL QUEZADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RICARDO MANUEL QUEZADA REAL M.D.

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 45TH AVE STE. 103
MUNSTER IN
46321-2893
US

IV. Provider business mailing address

757 45TH AVE STE. 201
MUNSTER IN
46321-2911
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-3002
  • Fax: 219-922-3003
Mailing address:
  • Phone: 219-993-4246
  • Fax: 219-934-2478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25794
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number01073108A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: