Provider Demographics
NPI:1083798821
Name:DR. ROBERTO MEDINA, MD LLC
Entity Type:Organization
Organization Name:DR. ROBERTO MEDINA, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-257-4470
Mailing Address - Street 1:415 SILAS DEANE HWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2124
Mailing Address - Country:US
Mailing Address - Phone:860-257-4470
Mailing Address - Fax:860-257-4479
Practice Address - Street 1:415 SILAS DEANE HWY
Practice Address - Street 2:SUITE 210
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2124
Practice Address - Country:US
Practice Address - Phone:860-257-4470
Practice Address - Fax:860-257-4479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CT034507261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG05318Medicare UPIN