Provider Demographics
NPI:1841742301
Name:PAUL R. QUINTAVALLE
Entity Type:Organization
Organization Name:PAUL R. QUINTAVALLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:QUINTAVALLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-858-0180
Mailing Address - Street 1:879 HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-1941
Mailing Address - Country:US
Mailing Address - Phone:856-858-0180
Mailing Address - Fax:858-869-3080
Practice Address - Street 1:879 HADDON AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-1941
Practice Address - Country:US
Practice Address - Phone:856-858-0180
Practice Address - Fax:858-869-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD00105600213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1735501Medicaid
NJT75586Medicare UPIN
NJ003671Medicare PIN