Provider Demographics
NPI:1700915311
Name:QUEL, JORGE ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ANTONIO
Last Name:QUEL
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 1:4644 LINCOLN BLVD STE 410
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6390
Mailing Address - Country:US
Mailing Address - Phone:310-823-6766
Mailing Address - Fax:310-823-6966
Practice Address - Street 1:4644 LINCOLN BLVD STE 410
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6390
Practice Address - Country:US
Practice Address - Phone:310-823-6766
Practice Address - Fax:310-823-6966
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24556207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24556OtherMEDICAL LICENSURE
CAA83043Medicare UPIN
CAA24556Medicare ID - Type Unspecified