Provider Demographics
NPI:1043464993
Name:MEDINA, RAUL
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 192 BOX 70011
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:787-889-0039
Mailing Address - Fax:
Practice Address - Street 1:CALLE PRINCIPAL J23 VISTAS DE LUQUILLO
Practice Address - Street 2:
Practice Address - City:LUQUILLO
Practice Address - State:PR
Practice Address - Zip Code:00773
Practice Address - Country:US
Practice Address - Phone:787-889-0039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTC AMB 3073416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0056563Medicare PIN