Provider Demographics
NPI:1215432901
Name:QUALLEY, JASON (MD, CCP,LP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:QUALLEY
Suffix:
Gender:M
Credentials:MD, CCP,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 DEFENSE HWY STE 205
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7096
Mailing Address - Country:US
Mailing Address - Phone:855-527-7246
Mailing Address - Fax:866-229-5063
Practice Address - Street 1:182 E REDSTONE AVE STE A
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5371
Practice Address - Country:US
Practice Address - Phone:855-527-7246
Practice Address - Fax:833-905-2461
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX613883207R00000X
FLME165604208M00000X, 208VP0014X
242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121439800Medicaid