Healthcare Provider Details

I. General information

NPI: 1245847094
Provider Name (Legal Business Name): KEVIN A BUENAHORA MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 06/20/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 CALLE MAGA URB. MANSIONES DE LOS CEDROS
CAYEY PR
00736
US

IV. Provider business mailing address

161 CALLE MAGA URB. MANSIONES DE LOS CEDROS
CAYEY PR
00736
US

V. Phone/Fax

Practice location:
  • Phone: 787-604-3317
  • Fax:
Mailing address:
  • Phone: 787-604-3317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number22-022
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number22-022
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: