Provider Demographics
NPI:1215352703
Name:QUARLES, LUTHER IV
Entity type:Individual
Prefix:
First Name:LUTHER
Middle Name:
Last Name:QUARLES
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:1760 EDGEWOOD AVE W STE A&B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208
Practice Address - Country:US
Practice Address - Phone:904-358-8480
Practice Address - Fax:904-358-8460
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine