Provider Demographics
NPI:1285861211
Name:MEDINA, EDWARD C (IDMT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:MEDINA
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 5425
Mailing Address - Street 2:CAMP BULLIS
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-0000
Mailing Address - Country:US
Mailing Address - Phone:210-295-8337
Mailing Address - Fax:210-295-8191
Practice Address - Street 1:RR 2 BOX 5425
Practice Address - Street 2:CAMP BULLIS
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-0000
Practice Address - Country:US
Practice Address - Phone:210-295-8337
Practice Address - Fax:210-295-8191
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians