MEDICARE: ANGEL LUIS MEDINA ORTA

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	208D00000X	General Practice Physician	22601	PR

General Provider Information

NPI Number	:	1720733710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL LUIS MEDINA ORTA

Provider Business Mailing Address
First Line	:	URB SANTA CLARA CALLE 5 #222
Second Line	:
City	:	SAN LORENZO
State	:	PR
Zip	:	00754-9998
Country	:	US
Telephone Number	:	787-672-8753
Fax Number	:

Provider Business Practice Location Address
First Line	:	URB SANTA CLARA CALLE 5 #222
Second Line	:
City	:	SAN LORENZO
State	:	PR
Zip	:	00754-9998
Country	:	US
Telephone Number	:	787-672-8753
Fax Number	:

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

Provider Enumeration Date	:	02/17/2022
Last Update Date	:	02/17/2022

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