Provider Demographics
NPI:1467402164
Name:HIDALGO MEDINA, MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:HIDALGO MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MANUEL
Other - Middle Name:
Other - Last Name:HIDALGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1305 YORK AVE RM Y&41
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 YORK AVE RM Y741
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5663
Practice Address - Country:US
Practice Address - Phone:646-962-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD58492207RH0003X
NY298682207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403130000Medicaid
MDH16032Medicare UPIN