Healthcare Provider Details

I. General information

NPI: 1003306135
Provider Name (Legal Business Name): ABELARDO MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 J DEWEY GRAY CIR STE 300
AUGUSTA GA
30909-1868
US

IV. Provider business mailing address

PO BOX 3726
AUGUSTA GA
30914-3726
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9595
  • Fax: 706-868-8375
Mailing address:
  • Phone: 706-863-9595
  • Fax: 706-868-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number95270
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: