Healthcare Provider Details

I. General information

NPI: 1538654942
Provider Name (Legal Business Name): FABIAN ANTONIO RODRIGUEZ QUINONEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD STE 1
PHILADELPHIA PA
19141-3098
US

IV. Provider business mailing address

5501 OLD YORK RD STE 1
PHILADELPHIA PA
19141-3098
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-7890
  • Fax:
Mailing address:
  • Phone: 215-456-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT216935
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD479368
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: