Healthcare Provider Details

I. General information

NPI: 1417659160
Provider Name (Legal Business Name): VICTOR JAVIER MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 ELLIOTT ST STE S1
KEWANEE IL
61443-2776
US

IV. Provider business mailing address

519 ELLIOTT ST STE S1
KEWANEE IL
61443-2776
US

V. Phone/Fax

Practice location:
  • Phone: 309-853-2442
  • Fax: 309-853-3640
Mailing address:
  • Phone: 309-853-2442
  • Fax: 309-853-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.177031
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.177031
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA197207
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME1777341
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: