=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104313246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN SPENCER QUINONEZ DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2018
-----------------------------------------------------
Last Update Date | 07/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6450 38TH AVE N STE 400
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-1653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-545-4444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6923 STONES THROW CIR N APT 4203
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-4779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-425-1138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS17525
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------