Provider Demographics
NPI:1457518490
Name:QUINTANILLA-DIECK, MARIA JOSEFINA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JOSEFINA
Last Name:QUINTANILLA-DIECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 LEGACY CIR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-3161
Mailing Address - Country:US
Mailing Address - Phone:630-300-0015
Mailing Address - Fax:
Practice Address - Street 1:1519 LEGACY CIR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3161
Practice Address - Country:US
Practice Address - Phone:630-473-8901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9937207N00000X
MI4301091563207N00000X, 207ND0101X
IL036154214207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283860904OtherARC ROT MEDICAID
TX372614YKXVOtherARC TRAVIS MEDICARE
TX283860903OtherARC TRAVIS MEDICAID
TX372614YKXYOtherARC ROT MEDICARE
MI4301091563OtherMICHIGAN LIMITED EDUCATION LICENSE