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General NPI Number Information
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NPI Number | 1063850147
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Entity Type | Individual
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Provider Name | ROBERTO EDUARDO MEDINA M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/11/2013
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Last Update Date | 04/20/2021
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Provider Practice Location Address
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Address Line | 309 JACKSON ST
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City | MONROE
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State | LA
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Zip | 71201-7407
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Country | US
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Telephone | 806-831-8734
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Fax | 940-205-5028
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Provider Business Mailing Address
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Address Line | 309 JACKSON ST
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City | MONROE
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State | LA
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Zip | 71201-7407
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Country | US
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Telephone | 806-831-8734
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Fax | 402-055-0289
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 311630
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | BP10045433
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 29919
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License Number State | OK
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Taxonomy #4
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | BP10045433
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 29919
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License Number State | OK
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