Healthcare Provider Details

I. General information

NPI: 1093786444
Provider Name (Legal Business Name): CARLO MEDINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 05/01/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 ADMIRALTY WAY STE 201
MARINA DEL REY CA
90292-5425
US

IV. Provider business mailing address

1626 MONTANA AVE # 631
SANTA MONICA CA
90403-1808
US

V. Phone/Fax

Practice location:
  • Phone: 310-823-3443
  • Fax: 310-305-7470
Mailing address:
  • Phone: 310-823-3443
  • Fax: 310-305-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC53912
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberC53912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: