1770543514 NPI number — DR. NELSON R MEDINA M.D.

Table of content: DR. NELSON R MEDINA M.D. (NPI 1770543514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770543514 NPI number — DR. NELSON R MEDINA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
NELSON
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDINA
Provider Other First Name:
NELSON
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770543514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 332228
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00733-2228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-813-2385
Provider Business Mailing Address Fax Number:
787-984-1691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 TORRE SAN CRISTOBAL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COTO LAUREL
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00780-2856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-813-2385
Provider Business Practice Location Address Fax Number:
787-984-1691
Provider Enumeration Date:
03/24/2006

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: 207RG0100X , with the licence number:  12324 , 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)

  • Identifier: 037630002 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 403255022 . This is a "PROSAM" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 600932 . This is a "MEDICARE Y MUCHO MAS" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 09312324 . This is a "GLOBAL HEATH" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 214131 . This is a "PREFERRED MEDICAL" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 3561 . This is a "FISRT MEDICAL" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 1808 . This is a "PREFERRED MEDICAL CHOICE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 5012324 . This is a "AUTORIDAD DE ACUEDUCTOS" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: SE4203 . This is a "PALIC" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 061067 . This is a "CRUZ AZUL DE PR" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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