Healthcare Provider Details

I. General information

NPI: 1386627313
Provider Name (Legal Business Name): JAIME MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 BURRSTONE RD
NEW HARTFORD NY
13413-1001
US

IV. Provider business mailing address

1729 BURRSTONE RD
NEW HARTFORD NY
13413-1001
US

V. Phone/Fax

Practice location:
  • Phone: 315-798-1700
  • Fax: 315-798-1707
Mailing address:
  • Phone: 315-798-1700
  • Fax: 315-798-1707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number128675
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: