Provider Demographics
NPI:1255494092
Name:MEDINA, TYRONE J (MD)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:J
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 1:400 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5519
Mailing Address - Country:US
Mailing Address - Phone:239-261-5511
Mailing Address - Fax:239-649-3301
Practice Address - Street 1:400 8TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5519
Practice Address - Country:US
Practice Address - Phone:239-261-5511
Practice Address - Fax:239-649-3301
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2009-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59671207P00000X
FLME0059671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00107425OtherRRMC
FL12203OtherBCBS
FL371615500Medicaid
F00756Medicare UPIN
FL371615500Medicaid