Provider Demographics
NPI:1700055530
Name:CULLIVAN, JESSICA QUANTZ (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:QUANTZ
Last Name:CULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:QUANTZ
Other - Last Name:RATLIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 PALMER AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311
Mailing Address - Country:US
Mailing Address - Phone:937-599-7018
Mailing Address - Fax:937-599-5011
Practice Address - Street 1:205 PALMER AVENUE
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311
Practice Address - Country:US
Practice Address - Phone:937-599-7018
Practice Address - Fax:937-599-5011
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35091140207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2866975Medicaid
OH2866975Medicaid