1215765193 NPI number — MS. EDANILKA MEDINA SUSTACHE PHD

Table of content: MS. EDANILKA MEDINA SUSTACHE PHD (NPI 1215765193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215765193 NPI number — MS. EDANILKA MEDINA SUSTACHE PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA SUSTACHE
Provider First Name:
EDANILKA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1215765193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
URB. LOS ARBOLES 341 GRANADA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO GRANDE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-602-0547
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
URB. LOS ARBOLES 341 GRANADA STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO GRANDE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-602-0547
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2024

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: 103TC0700X , with the licence number:  6832 , 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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