Provider Demographics
NPI:1093902496
Name:QUEVEDO, JUAN MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
Last Name:QUEVEDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:40 VALLEY STREAM PKWY # 100
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:610-644-8900
Mailing Address - Fax:
Practice Address - Street 1:995 GATEWAY CENTER WAY STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4544
Practice Address - Country:US
Practice Address - Phone:619-263-9729
Practice Address - Fax:619-263-9730
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR17941207R00000X
NY279615207RN0300X
CAA144881207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine