MEDICARE: DR. IRMA MEDINA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	L0867	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	89613X	OTHER	TX	BC/BS OF TEXAS

General Provider Information

NPI Number	:	1477669034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRMA MEDINA M.D.

Provider Business Mailing Address
First Line	:	11335 SSG SIMS
Second Line	:
City	:	FT BLISS
State	:	TX
Zip	:	79918
Country	:	US
Telephone Number	:	915-742-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	11335 SSG SIMS
Second Line	:
City	:	FT BLISS
State	:	TX
Zip	:	79918
Country	:	US
Telephone Number	:	915-742-2273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	11/13/2023

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