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General NPI Number Information
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NPI Number | 1053584011
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Entity Type | Organization
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Legal Business Name | MIGUEL A MEDINA MD PA
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Dates
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Enumeration Date | 04/10/2008
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Last Update Date | 08/17/2009
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Provider Practice Location Address
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Address Line | 119 S PARK AVE
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City | TITUSVILLE
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State | FL
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Zip | 32796-3377
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Country | US
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Telephone | 321-264-8644
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Fax | 321-264-8933
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Provider Business Mailing Address
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Address Line | 119 S PARK AVE
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City | TITUSVILLE
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State | FL
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Zip | 32796-3377
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Country | US
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Telephone | 321-264-8644
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Fax | 321-264-8933
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MIGUEL ANGEL MEDINA
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Credential | MD
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Telephone | 321-268-6111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME0097000
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License Number State | FL
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