Provider Demographics
NPI:1053502435
Name:QUEZADA, RICARDO MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:MANUEL
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICARDO
Other - Middle Name:MANUEL
Other - Last Name:QUEZADA REAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:757 45TH AVE
Mailing Address - Street 2:STE. 201
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2911
Mailing Address - Country:US
Mailing Address - Phone:219-993-4246
Mailing Address - Fax:219-934-2478
Practice Address - Street 1:761 45TH AVE
Practice Address - Street 2:STE. 103
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2893
Practice Address - Country:US
Practice Address - Phone:219-922-3002
Practice Address - Fax:219-922-3003
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073108A207RI0200X
OK25794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine