Provider Demographics
NPI:1861495137
Name:QUIGLEY, JACK B (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:QUIGLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:B
Other - Last Name:QUIGLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1020 N SAN FRANCISCO ST
Mailing Address - Street 2:# 200
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3281
Mailing Address - Country:US
Mailing Address - Phone:928-774-2300
Mailing Address - Fax:928-214-2150
Practice Address - Street 1:1020 N SAN FRANCISCO ST
Practice Address - Street 2:# 200
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3281
Practice Address - Country:US
Practice Address - Phone:928-774-2300
Practice Address - Fax:928-214-2150
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20243208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2004440OtherCIGNA
AZAZ0355110OtherBLUE CROSS BLUE SHIELD AZ
AZ054768Medicaid
AZ18032746OtherSTATE COMP AZ
AZ20243OtherAZ LICENSE
AZP054768Medicaid
AZ8607474153000OtherTAX ID
AZP054768Medicaid
AZ054768Medicaid