Provider Demographics
NPI:1265485106
Name:MEDINA, JUAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:M
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 1:320 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1648
Mailing Address - Country:US
Mailing Address - Phone:217-854-3166
Mailing Address - Fax:
Practice Address - Street 1:320 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1748
Practice Address - Country:US
Practice Address - Phone:217-854-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF84811Medicare UPIN
ILL88529Medicare ID - Type Unspecified
ILK20953Medicare PIN