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General NPI Number Information
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NPI Number | 1669832846
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Entity Type | Individual
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Provider Name | CHRISTOPHER MEDINA O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/01/2016
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Last Update Date | 03/01/2016
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Provider Practice Location Address
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Address Line | CONCOURSE 4 MICRONESIA MALL IDEAL OPTICAL
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City | DEDEDO
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State | GU
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Zip | 96929
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Country | US
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Telephone | 671-637-8141
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 24724
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City | BARRIGADA
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State | GU
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Zip | 96921-4724
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Country | US
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Telephone |
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Fax |
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OL-029
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License Number State | GU
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | OL-029
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License Number State | GU
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