Provider Demographics
NPI:1033123914
Name:QUEZADA, CARLOS ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ALBERTO
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 JOHNSTON DR
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-4927
Mailing Address - Country:US
Mailing Address - Phone:908-723-0224
Mailing Address - Fax:908-755-9326
Practice Address - Street 1:370 GRAND AVE
Practice Address - Street 2:102
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4154
Practice Address - Country:US
Practice Address - Phone:201-567-3370
Practice Address - Fax:201-816-1265
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05609900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF36082Medicare UPIN
NJ726191L4SMedicare ID - Type UnspecifiedPHYSICIAN