Healthcare Provider Details

I. General information

NPI: 1427049972
Provider Name (Legal Business Name): MIGUEL A MEDINA RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 N COURTENAY PKWY
MERRITT ISLAND FL
32953-4126
US

IV. Provider business mailing address

2575 N COURTENAY PKWY
MERRITT ISLAND FL
32953-4126
US

V. Phone/Fax

Practice location:
  • Phone: 321-454-7148
  • Fax: 321-449-5015
Mailing address:
  • Phone: 321-454-7148
  • Fax: 321-449-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12542
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number12542
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: