Provider Demographics
NPI:1639151921
Name:QUACKENBUSH, JEFFREY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:QUACKENBUSH
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:DEPT 6064
Mailing Address - Street 2:
Mailing Address - City:CAROL STREET
Mailing Address - State:IL
Mailing Address - Zip Code:60122
Mailing Address - Country:US
Mailing Address - Phone:219-462-8246
Mailing Address - Fax:219-462-7902
Practice Address - Street 1:54 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5845
Practice Address - Country:US
Practice Address - Phone:219-462-8246
Practice Address - Fax:219-462-7902
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055750A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000228984OtherANTHEMBCBS
IN200371010AMedicaid
IN200371010AMedicaid