Provider Demographics
NPI:1255456661
Name:QUATTLEBAUM, MALCOLM RANDALL
Entity type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:RANDALL
Last Name:QUATTLEBAUM
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 1:3090 FM 317
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75752-5796
Mailing Address - Country:US
Mailing Address - Phone:903-675-5900
Mailing Address - Fax:903-675-5900
Practice Address - Street 1:3090 FM 317
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75752-5796
Practice Address - Country:US
Practice Address - Phone:903-675-5900
Practice Address - Fax:903-675-5900
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0079342332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX507686OtherBLUE CROSS BLUE SHIELD
TX0571210001Medicare NSC