Provider Demographics
NPI:1417089152
Name:QUITERIO, SHANE J (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:J
Last Name:QUITERIO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28155 PATHFINDER CT
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1805
Mailing Address - Country:US
Mailing Address - Phone:410-422-7341
Mailing Address - Fax:443-773-4700
Practice Address - Street 1:28155 PATHFINDER CT
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-1805
Practice Address - Country:US
Practice Address - Phone:410-422-7341
Practice Address - Fax:443-773-4700
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD450838207P00000X
DEC1-0008387207P00000X
DEC7-0003215207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1417089152OtherBLUE SHIELD
PA102924881Medicaid
DE1417089152Medicaid