Provider Demographics
NPI:1235182650
Name:MEDINA, STEPHEN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CARLOS
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 1:1501 N FLORENCE
Mailing Address - Street 2:STE 250
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3256
Mailing Address - Country:US
Mailing Address - Phone:918-343-8513
Mailing Address - Fax:918-341-7090
Practice Address - Street 1:1501 N FLORENCE AVE STE 250
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3256
Practice Address - Country:US
Practice Address - Phone:918-343-8513
Practice Address - Fax:918-341-7090
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20083207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100215260AMedicaid
OKF40170Medicare UPIN
OKOKAAA2276Medicare PIN