1396027991 NPI number — DR. SANDRA P MEDINILLA MD

Table of content: DR. SANDRA P MEDINILLA MD (NPI 1396027991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396027991 NPI number — DR. SANDRA P MEDINILLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINILLA
Provider First Name:
SANDRA
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1396027991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HYGEIA DRIVE
Provider Second Line Business Mailing Address:
SUITE 2374
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-623-7113
Provider Business Mailing Address Fax Number:
302-623-7397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4735 OGLETOWN STANTON ROAD
Provider Second Line Business Practice Location Address:
MAP 2, SUITE 3301
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-623-4370
Provider Business Practice Location Address Fax Number:
302-623-4375
Provider Enumeration Date:
09/09/2011

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: 2086S0102X , with the licence number:  C1-0010075 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: 4301500497 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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