Provider Demographics
NPI:1154314342
Name:MEDINA, MARELYN (MD)
Entity Type:Individual
Prefix:
First Name:MARELYN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 E DOVE AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2240
Mailing Address - Country:US
Mailing Address - Phone:956-686-7243
Mailing Address - Fax:956-668-7123
Practice Address - Street 1:412 E DOVE AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2240
Practice Address - Country:US
Practice Address - Phone:956-686-7243
Practice Address - Fax:956-668-7123
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9759208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340017711OtherRAILROAD MEDICARE
3196639OtherBCBS BLUE LINK
82010YOtherBCBS
TX16886101Medicaid
TX036004201Medicaid
1258210001OtherPALMETTO DME
1258210001OtherPALMETTO DME
TX16886101Medicaid
D96639Medicare UPIN