Provider Demographics
NPI:1346308855
Name:QUILALA, MARLENE (MD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:QUILALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 BLACK ROCK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453
Mailing Address - Country:US
Mailing Address - Phone:707-262-1634
Mailing Address - Fax:
Practice Address - Street 1:359 LAKEPORT BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5412
Practice Address - Country:US
Practice Address - Phone:707-533-2740
Practice Address - Fax:707-263-5400
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA063667208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
05137251OtherECFMG
G68990Medicare UPIN