Provider Demographics
NPI:1164418752
Name:MEDINA, LUIS A
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
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 3377
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77643-3377
Mailing Address - Country:US
Mailing Address - Phone:409-722-6100
Mailing Address - Fax:409-722-6109
Practice Address - Street 1:3800 HIGHWAY 365
Practice Address - Street 2:#119
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-7526
Practice Address - Country:US
Practice Address - Phone:409-722-6100
Practice Address - Fax:409-722-6109
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2013-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029674101Medicaid
G78225Medicare UPIN
00147GMedicare ID - Type Unspecified