Healthcare Provider Details

I. General information

NPI: 1396027991
Provider Name (Legal Business Name): SANDRA P MEDINILLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 OGLETOWN STANTON ROAD MAP 2, SUITE 3301
NEWARK DE
19713-0000
US

IV. Provider business mailing address

200 HYGEIA DRIVE SUITE 2374
NEWARK DE
19713-2049
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-4370
  • Fax: 302-623-4375
Mailing address:
  • Phone: 302-623-7113
  • Fax: 302-623-7397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberC1-0010075
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number4301500497
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: