Healthcare Provider Details

I. General information

NPI: 1538308036
Provider Name (Legal Business Name): EZEQUIEL MEDINA RODRIGUEZ M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2009
Last Update Date: 02/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND SANTA RITA # 1000
SAN JUAN PR
00925-2857
US

IV. Provider business mailing address

PO BOX 141446
ARECIBO PR
00614-1446
US

V. Phone/Fax

Practice location:
  • Phone: 787-633-3335
  • Fax:
Mailing address:
  • Phone: 787-633-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3270
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: