Provider Demographics
NPI:1407983372
Name:MEDINA, TANIA (MD)
Entity Type:Individual
Prefix:DR
First Name:TANIA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S ALVARADO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2201
Mailing Address - Country:US
Mailing Address - Phone:323-987-1413
Mailing Address - Fax:323-987-1400
Practice Address - Street 1:123 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2201
Practice Address - Country:US
Practice Address - Phone:323-987-1413
Practice Address - Fax:323-987-1400
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051007Medicare Oscar/Certification