=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700915311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE ANTONIO QUEL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4644 LINCOLN BLVD STE 410
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-6390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-823-6766
-----------------------------------------------------
Fax | 310-823-6966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4644 LINCOLN BLVD STE 410
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-6390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-823-6766
-----------------------------------------------------
Fax | 310-823-6966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | A24556
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------