Healthcare Provider Details

I. General information

NPI: 1982773982
Provider Name (Legal Business Name): IGNACIO MEDINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PELHAM PKWY S BUILDING #4 ROOM 4 SOUTH 10
BRONX NY
10461-1138
US

IV. Provider business mailing address

1400 PELHAM PKWY S BUILDING #4 ROOM 4 SOUTH 10
BRONX NY
10461-1138
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-3460
  • Fax: 718-918-7526
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number193912
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: