1558353441 NPI number — DR. SIXTO MANUEL MEDINA JACA MD

Table of content: DR. SIXTO MANUEL MEDINA JACA MD (NPI 1558353441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558353441 NPI number — DR. SIXTO MANUEL MEDINA JACA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA JACA
Provider First Name:
SIXTO
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558353441
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
B-3, 3 STREET PARQUE SAN IGNACIO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-786-5087
Provider Business Mailing Address Fax Number:
787-787-1593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BAYAMON MEDICAL PLAZA SUITE 405
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-786-5087
Provider Business Practice Location Address Fax Number:
787-787-1593
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  4735 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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