=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386183382
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATALIE MEDINA, MD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2017
-----------------------------------------------------
Last Update Date | 02/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 EUCLID AVE SUITE 306
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-267-1168
-----------------------------------------------------
Fax | 619-267-6644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1404
-----------------------------------------------------
City | BONITA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91908-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-267-1168
-----------------------------------------------------
Fax | 619-267-6644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NATALIE JO MEDINA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 619-995-0990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | A54817
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------