Provider Demographics
NPI:1790779825
Name:QUETELL, GUILLERMO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:QUETELL
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 1:5000 BRITTONFIELD PKWY STE A125
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9230
Mailing Address - Country:US
Mailing Address - Phone:315-802-2601
Mailing Address - Fax:315-802-6933
Practice Address - Street 1:5000 BRITTONFIELD PKWY STE A125
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9230
Practice Address - Country:US
Practice Address - Phone:315-802-2601
Practice Address - Fax:315-802-6933
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188329208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02281818Medicaid
NYG75209Medicare UPIN
NYRA0617Medicare PIN