Provider Demographics
NPI:1275521312
Name:MEDINA, EDMOND (MD)
Entity Type:Individual
Prefix:MR
First Name:EDMOND
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:ME8 PLAZA 12
Mailing Address - Street 2:URB. MONTE CLARO
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-4776
Mailing Address - Country:US
Mailing Address - Phone:787-785-9282
Mailing Address - Fax:787-785-9290
Practice Address - Street 1:P12 AVE MAGNOLIA
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-2608
Practice Address - Country:US
Practice Address - Phone:787-785-9282
Practice Address - Fax:787-785-9290
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR095213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0071096Medicare PIN
PRU91418Medicare UPIN
PR0084968AMedicare PIN