Healthcare Provider Details

I. General information

NPI: 1548545809
Provider Name (Legal Business Name): ALAN MEDINA, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 08/14/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 NEW WATER OAK DR
PALM COAST FL
32137-6958
US

IV. Provider business mailing address

19 NEW WATER OAK DR
PALM COAST FL
32137-6958
US

V. Phone/Fax

Practice location:
  • Phone: 917-856-6519
  • Fax: 386-597-2948
Mailing address:
  • Phone: 917-856-6519
  • Fax: 386-597-2948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number170738
License Number StateNY

VIII. Authorized Official

Name: ALAN MEDINA
Title or Position: PRESIDENT
Credential: MD
Phone: 917-856-6519