Provider Demographics
NPI:1326187626
Name:MEDINA, JUAN A (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:A
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 1:1695 FULTON AVE
Mailing Address - Street 2:#2N
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-8131
Mailing Address - Country:US
Mailing Address - Phone:646-463-3538
Mailing Address - Fax:
Practice Address - Street 1:870 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4660
Practice Address - Country:US
Practice Address - Phone:718-337-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245701207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine