Provider Demographics
NPI:1033371596
Name:ROHENA-QUINQUILLA, IVAN RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:RAFAEL
Last Name:ROHENA-QUINQUILLA
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:PO BOX 9263
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-9263
Mailing Address - Country:US
Mailing Address - Phone:706-320-2773
Mailing Address - Fax:706-596-4226
Practice Address - Street 1:2122 MANCHESTER EXPY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6878
Practice Address - Country:US
Practice Address - Phone:706-320-2773
Practice Address - Fax:706-596-4226
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA0704182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program