Provider Demographics
NPI:1093786444
Name:MEDINA, CARLO (MD)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-226-6571
Mailing Address - Fax:323-226-2718
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-226-6571
Practice Address - Fax:323-226-2718
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53912207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CAGR0100430OtherGROUP MEDICAL
H76953Medicare UPIN
60S191Medicare ID - Type Unspecified