Healthcare Provider Details

I. General information

NPI: 1558743922
Provider Name (Legal Business Name): MICHEL MEDINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 EUREKA RD
ROSEVILLE CA
95661-3027
US

IV. Provider business mailing address

1600 EUREKA RD BUILDING C, 4TH FLOOR, MEMORY CENTER
ROSEVILLE CA
95661-3027
US

V. Phone/Fax

Practice location:
  • Phone: 916-474-6464
  • Fax:
Mailing address:
  • Phone: 916-474-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberA162135
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA162135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: