=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780714873
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRNA SOCORRO AMARO MEDINA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 893 CALLE EIDER
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-2371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-768-6996
-----------------------------------------------------
Fax | 787-768-6996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 29454 65TH INFANTRY STATION
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00929-0454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-768-6996
-----------------------------------------------------
Fax | 787-768-6996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 10297
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 10297
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------