=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144924804
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VALERY MEDINA OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2023
-----------------------------------------------------
Last Update Date | 09/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MINOR HALL
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94720-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-642-6123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 EMERY BAY DR
-----------------------------------------------------
City | EMERYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94608-2920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-887-2985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT35640-TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | ATI4672
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------