Individual
DR. JEFFREY JOHN QUACKENBUSH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
54 ROOSEVELT RD, VALPARAISO, IN 46383-5845
(219) 462-8246
(219) 462-7902
Mailing address
DEPT 6064, CAROL STREET, IL 60122
(219) 462-8246
(219) 462-7902
Taxonomy
Speciality
Code
Description
License number
State
2085R0001X
Radiation Oncology Physician
Primary
01055750A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000228984
ANTHEMBCBS
IN
05
—
200371010A
—
IN
Enumeration date
11/14/2005
Last updated
07/22/2010
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