Provider Demographics
NPI:1093852113
Name:MEDINA, TEODORO (MD)
Entity Type:Individual
Prefix:
First Name:TEODORO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TEODORO
Other - Middle Name:MEDINA
Other - Last Name:MONTANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6675 WESTWOOD BLVD
Mailing Address - Street 2:STE 475
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:111 WEBB DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3962
Practice Address - Country:US
Practice Address - Phone:863-421-9447
Practice Address - Fax:863-421-1806
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14489208D00000X
FLACN 793208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTW49TOtherFL BLUE