Provider Demographics
NPI:1912090622
Name:STEWART W QUISLING, MD INC
Entity Type:Organization
Organization Name:STEWART W QUISLING, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:QUISLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-523-5195
Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:3340 TULLY RD
Practice Address - Street 2:SUITE D-2
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-523-5195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3230002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA183864900OtherDEPT OF LABOR
CA00C323000Medicare ID - Type Unspecified