Healthcare Provider Details

I. General information

NPI: 1598189060
Provider Name (Legal Business Name): DAVID ALLAN QUACKENBUSH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050A 2ND ST SE
KIRTLAND AFB NM
87117-2502
US

IV. Provider business mailing address

PO BOX 56853
ALBUQUERQUE NM
87187-6853
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3200
  • Fax:
Mailing address:
  • Phone: 682-241-6707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102204210
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number0102204210
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: