1962569392 NPI number — SAMUEL MEDINA

Table of content: SAMUEL MEDINA (NPI 1962569392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962569392 NPI number — SAMUEL MEDINA

Organization/Personal Information

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

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:
1962569392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
C18 CALLE 5
Provider Second Line Business Mailing Address:
ESTANCIAS DE SAN FERNANDO
Provider Business Mailing Address City Name:
CAROLINA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00985-5215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-438-4798
Provider Business Mailing Address Fax Number:
787-768-4977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
C18 CALLE 5
Provider Second Line Business Practice Location Address:
ESTANCIAS DE SAN FERNANDO
Provider Business Practice Location Address City Name:
CAROLINA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00985-5215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-438-4798
Provider Business Practice Location Address Fax Number:
787-768-4977
Provider Enumeration Date:
01/03/2007

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: 183500000X , with the licence number:  2199 , 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: 0720683 . This is a "DRIVERS LICENCE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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