Provider Demographics
NPI:1740276500
Name:QUENNEVILLE, DANIEL JASON (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JASON
Last Name:QUENNEVILLE
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 1:5643 WOODMANSEE WAY
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-5914
Mailing Address - Country:US
Mailing Address - Phone:937-241-1670
Mailing Address - Fax:
Practice Address - Street 1:5643 WOODMANSEE WAY
Practice Address - Street 2:
Practice Address - City:LIBERTY TWP
Practice Address - State:OH
Practice Address - Zip Code:45011-5914
Practice Address - Country:US
Practice Address - Phone:937-241-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0807432085R0202X
MI43010527462085R0202X
IL361174362085R0202X
AK35692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology