Healthcare Provider Details

I. General information

NPI: 1366831703
Provider Name (Legal Business Name): JOSE GABRIEL MEDINA-SMESTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BRICKELL AVE STE 954
MIAMI FL
33131-2951
US

IV. Provider business mailing address

PO BOX 3550
VALDOSTA GA
31604-3550
US

V. Phone/Fax

Practice location:
  • Phone: 786-375-5098
  • Fax: 229-245-7661
Mailing address:
  • Phone: 229-247-1667
  • Fax: 229-245-7661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME117746
License Number StateFL

VIII. Authorized Official

Name: DR. JOSE GABRIEL MEDINA-SMESTER
Title or Position: OWNER
Credential: MD
Phone: 229-247-1667