Healthcare Provider Details

I. General information

NPI: 1063850147
Provider Name (Legal Business Name): ROBERTO EDUARDO MEDINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

309 JACKSON ST
MONROE LA
71201-7407
US

V. Phone/Fax

Practice location:
  • Phone: 806-831-8734
  • Fax: 940-205-5028
Mailing address:
  • Phone: 806-831-8734
  • Fax: 402-055-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number311630
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10045433
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number29919
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberBP10045433
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number29919
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: