Healthcare Provider Details

I. General information

NPI: 1902895352
Provider Name (Legal Business Name): EDWIN M QUINONES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300B W RAILROAD ST
GULFPORT MS
39501-2568
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-863-7393
  • Fax: 228-868-6643
Mailing address:
  • Phone: 228-863-7393
  • Fax: 228-868-6643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number13479
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: