Provider Demographics
NPI:1093883258
Name:MEDINA, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
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 1810, PMB 753
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-1810
Mailing Address - Country:US
Mailing Address - Phone:787-832-3066
Mailing Address - Fax:787-831-3605
Practice Address - Street 1:25 CALLE PERAL N
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4820
Practice Address - Country:US
Practice Address - Phone:787-832-3066
Practice Address - Fax:787-831-3605
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F07640Medicare UPIN
82485Medicare ID - Type Unspecified