MEDICARE: DR. EVARISTO QUINONES M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	10703	PR

General Provider Information

NPI Number	:	1043215965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVARISTO QUINONES M.D.

Provider Business Mailing Address
First Line	:	125 CALLE MARINA
Second Line	:	MANS PLAYA HUCARES
City	:	NAGUABO
State	:	PR
Zip	:	00718-2875
Country	:	US
Telephone Number	:	580-695-6422
Fax Number	:	787-874-4292

Provider Business Practice Location Address
First Line	:	4303 PITMAN & THOMAS RD
Second Line	:
City	:	FORT SILL
State	:	OK
Zip	:	73503
Country	:	US
Telephone Number	:	580-585-5640
Fax Number	:	580-585-5680

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	10/17/2013

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