=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639193923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS A MEDINA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 NW 12TH AVE M851
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33101-6960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-243-4029
-----------------------------------------------------
Fax | 305-243-8470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 NW 12TH AVE BOX 016960 M851
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33101-6960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-243-4029
-----------------------------------------------------
Fax | 305-243-8470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | ME60360
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VF0040X
-----------------------------------------------------
Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
-----------------------------------------------------
License Number | ME60360
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------