Healthcare Provider Details

I. General information

NPI: 1922005701
Provider Name (Legal Business Name): MANUEL MEDINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

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

III. Provider practice location address

1801 AVE PONCE DE LEON SUITE 304
SAN JUAN PR
00909-1900
US

IV. Provider business mailing address

1801 AVE PONCE DE LEON SUITE 304
SAN JUAN PR
00909-1900
US

V. Phone/Fax

Practice location:
  • Phone: 787-268-3192
  • Fax: 787-268-3191
Mailing address:
  • Phone: 787-268-3192
  • Fax: 787-268-3191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number6783
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: