Healthcare Provider Details

I. General information

NPI: 1972749216
Provider Name (Legal Business Name): CELERINA B MEDINA MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 05/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4149 TWEEDY BLVD SUITE B
SOUTH GATE CA
90280-6167
US

IV. Provider business mailing address

4149 TWEEDY BLVD SUITE B
SOUTH GATE CA
90280-6167
US

V. Phone/Fax

Practice location:
  • Phone: 323-564-4545
  • Fax: 323-564-3063
Mailing address:
  • Phone: 323-564-4545
  • Fax: 323-564-3063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA45547
License Number StateCA

VIII. Authorized Official

Name: DR. CELERINA MEDINA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-564-4545