=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679572499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN SCOTT QUINBY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2005
-----------------------------------------------------
Last Update Date | 05/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17051 DALLAS PKWY STE 400
-----------------------------------------------------
City | ADDISON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75001-7108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-243-9390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 LONDON CT
-----------------------------------------------------
City | HEATH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75032-6865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-243-9390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | M1300
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------