1023419728 NPI number — DIANA MEDINA P.A.

Table of content: DIANA MEDINA P.A. (NPI 1023419728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023419728 NPI number — DIANA MEDINA P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
DIANA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

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:
1023419728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 GLADES CIR STE 136
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33327-2210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-738-2512
Provider Business Mailing Address Fax Number:
865-409-5715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 GLADES CIR STE 136
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33327-2210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-738-2512
Provider Business Practice Location Address Fax Number:
865-409-5715
Provider Enumeration Date:
09/12/2014

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: 363A00000X , with the licence number:  PA67616 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9108228 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PAT9108228 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: KP511 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y0R3E . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 013309400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 106041500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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