Provider Demographics
NPI:1164403895
Name:QUIROGA, GARY TRISTAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:TRISTAN
Last Name:QUIROGA
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 1:1027 S BRADFORD ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4141
Mailing Address - Country:US
Mailing Address - Phone:302-678-8981
Mailing Address - Fax:302-678-4706
Practice Address - Street 1:1027 S BRADFORD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4141
Practice Address - Country:US
Practice Address - Phone:302-678-8981
Practice Address - Fax:302-678-4706
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0D00925207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000137402Medicaid
DE080981Medicare ID - Type Unspecified
DE000137402Medicaid