Healthcare Provider Details

I. General information

NPI: 1538855366
Provider Name (Legal Business Name): JESSE NOEL MEDINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 11/28/2023
Certification Date: 04/14/2023
Deactivation Date: 11/17/2023
Reactivation Date: 11/28/2023

III. Provider practice location address

1611 NW 12 AVENUE, CENTRAL 600-D
MIAMI FL
33136
US

IV. Provider business mailing address

1611 NW 12 AVENUE, CENTRAL 600-D
MIAMI FL
33136
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5215
  • Fax:
Mailing address:
  • Phone: 305-585-5215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: