Provider Demographics
NPI:1205915840
Name:QUALLS, C BRANDON (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:BRANDON
Last Name:QUALLS
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 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:WELD BLDG
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-421-0060
Mailing Address - Fax:401-421-6616
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:WELD BLDG
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-421-0060
Practice Address - Fax:401-421-6616
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD049422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9001265Medicaid
RI9001265Medicaid
269093806Medicare ID - Type Unspecified