Provider Demographics
NPI:1922378272
Name:QUINTANA, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:QUINTANA
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 1:5935 W IRLO BRONSON HWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-4765
Mailing Address - Country:US
Mailing Address - Phone:407-396-1006
Mailing Address - Fax:407-396-9347
Practice Address - Street 1:5935 W IRLO BRONSON HWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-4765
Practice Address - Country:US
Practice Address - Phone:407-396-1006
Practice Address - Fax:407-396-9347
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS025589183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist