Provider Demographics
NPI:1063850147
Name:MEDINA, ROBERTO EDUARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:EDUARDO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7407
Mailing Address - Country:US
Mailing Address - Phone:806-831-8734
Mailing Address - Fax:402-055-0289
Practice Address - Street 1:309 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7407
Practice Address - Country:US
Practice Address - Phone:806-831-8734
Practice Address - Fax:940-205-5028
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA311630207P00000X
TXBP10045433207Q00000X, 207RG0300X
OK29919207QG0300X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine