Provider Demographics
NPI:1649227208
Name:QUAN, TIMOTHY EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:QUAN
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 1:1504 SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2711
Mailing Address - Country:US
Mailing Address - Phone:860-432-8400
Mailing Address - Fax:860-432-8430
Practice Address - Street 1:1504 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2711
Practice Address - Country:US
Practice Address - Phone:860-432-8400
Practice Address - Fax:860-432-8430
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037380207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2771375OtherCIGNA
CT010037380CT04OtherBLUE CROSS BLUE SHIELD
CT9924521OtherAETNA
CT1649227208Medicaid
812091188OtherTIN
CT1649227208Medicaid