Healthcare Provider Details

I. General information

NPI: 1841742301
Provider Name (Legal Business Name): PAUL R. QUINTAVALLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 HADDON AVE
COLLINGSWOOD NJ
08108-1941
US

IV. Provider business mailing address

879 HADDON AVE
COLLINGSWOOD NJ
08108-1941
US

V. Phone/Fax

Practice location:
  • Phone: 856-858-0180
  • Fax: 858-869-3080
Mailing address:
  • Phone: 856-858-0180
  • Fax: 858-869-3080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberMD00105600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberMD00105600
License Number StateNJ

VIII. Authorized Official

Name: PAUL R. QUINTAVALLE
Title or Position: OWNER
Credential: DPM
Phone: 856-858-0180