Healthcare Provider Details

I. General information

NPI: 1124966163
Provider Name (Legal Business Name): LOIDA QUIJANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE
BOSTON MA
02215-5491
US

IV. Provider business mailing address

19555 BENT TREE TER UNIT 103
LEESBURG VA
20176-1208
US

V. Phone/Fax

Practice location:
  • Phone: 617-632-8422
  • Fax: 617-632-9150
Mailing address:
  • Phone: 907-821-7401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number3020016
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: