Provider Demographics
NPI:1104847631
Name:QUEVEDO, JONATHAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:P
Last Name:QUEVEDO
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 1:65 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3947
Mailing Address - Country:US
Mailing Address - Phone:732-321-7000
Mailing Address - Fax:732-321-7330
Practice Address - Street 1:65 JAMES ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3947
Practice Address - Country:US
Practice Address - Phone:732-321-7000
Practice Address - Fax:732-321-7330
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA62010174400000X
NJ25MA06201000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC31521Medicare UPIN
NJQU140193Medicare ID - Type Unspecified
NJ3678008Medicare ID - Type Unspecified