Healthcare Provider Details

I. General information

NPI: 1356441968
Provider Name (Legal Business Name): MIGUEL A MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W COCOA BEACH CSWY
COCOA BEACH FL
32931
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-868-5871
  • Fax: 321-868-5852
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME97000
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: