Healthcare Provider Details

I. General information

NPI: 1376026781
Provider Name (Legal Business Name): JORGE HERNANDEZ MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 SW 107TH AVE STE A
MIAMI FL
33165-7344
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 365
MIAMI FL
33126-7010
US

V. Phone/Fax

Practice location:
  • Phone: 786-422-6525
  • Fax: 786-621-7815
Mailing address:
  • Phone: 786-322-7333
  • Fax: 786-347-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number21116
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1109
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: