Provider Demographics
NPI:1205814761
Name:MEDINA, MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
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 1498
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-1498
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR. #2 MARGINAL URB. VILLA REAL
Practice Address - Street 2:D-10
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:787-807-0900
Practice Address - Fax:787-855-2729
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR134462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH72052Medicare UPIN
PR20916Medicare PIN