Healthcare Provider Details

I. General information

NPI: 1164086369
Provider Name (Legal Business Name): LUIS AUGUSTO MEDINA MORA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date: 12/09/2019
Reactivation Date: 02/05/2020

III. Provider practice location address

12 ST PAUL DR STE 210
CHAMBERSBURG PA
17201-1035
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-217-6820
  • Fax: 717-217-6942
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD493662
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD493662
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: