Provider Demographics
NPI:1770216590
Name:QUEZADA, AUGUSTO RENE
Entity Type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:RENE
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 NEW YORK AVE NE FL 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3328
Mailing Address - Country:US
Mailing Address - Phone:202-673-2200
Mailing Address - Fax:
Practice Address - Street 1:1100 ALABAMA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4542
Practice Address - Country:US
Practice Address - Phone:202-299-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
DCPT26082251G0304X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1538254016Medicaid
DC1871634170Medicaid