MEDICARE: DR. LYDIA CAROLYN MEDINA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	444	PR

General Provider Information

NPI Number	:	1144532953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYDIA CAROLYN MEDINA O.D.

Provider Business Mailing Address
First Line	:	METRO OFFICE PARK # 3
Second Line	:	SUITE 108 PMB 206
City	:	GUAYNABO
State	:	PR
Zip	:	00968-1704
Country	:	US
Telephone Number	:	939-218-1157
Fax Number	:

Provider Business Practice Location Address
First Line	:	METRO OFFICE PARK # 3
Second Line	:	SUITE 108 PMB 206
City	:	GUAYNABO
State	:	PR
Zip	:	00968-1704
Country	:	US
Telephone Number	:	939-218-1157
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2010
Last Update Date	:	07/08/2010

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