1700242617 NPI number — CARLOS MEDINA MD PA

Table of content: (NPI 1700242617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700242617 NPI number — CARLOS MEDINA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARLOS MEDINA MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1700242617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 WATERSIDE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33019-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21110 BISCAYNE BLVD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVENTURA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-817-7808
Provider Business Practice Location Address Fax Number:
786-551-2299
Provider Enumeration Date:
01/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MEDINA
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
786-817-7808

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  ME106831 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ME106831 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 023725900 . 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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