MEDICARE: EZEQUIEL MEDINA RODRIGUEZ M.A.

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	103TB0200X	Cognitive & Behavioral Psychologist
2	103TC2200X	Clinical Child & Adolescent Psychologist
3	103TF0000X	Family Psychologist
4	103TM1800X	Intellectual & Developmental Disabilities Psychologist
5	103TS0200X	School Psychologist	3270	PR

General Provider Information

NPI Number	:	1538308036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EZEQUIEL MEDINA RODRIGUEZ M.A.

Provider Business Mailing Address
First Line	:	PO BOX 141446
Second Line	:
City	:	ARECIBO
State	:	PR
Zip	:	00614-1446
Country	:	US
Telephone Number	:	787-633-3335
Fax Number	:

Provider Business Practice Location Address
First Line	:	COND SANTA RITA # 1000
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00925-2857
Country	:	US
Telephone Number	:	787-633-3335
Fax Number	:

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

Provider Enumeration Date	:	02/07/2009
Last Update Date	:	02/07/2009

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