Provider Demographics
NPI:1467588186
Name:DR NELSON R MEDINA, MD C.S.P.
Entity Type:Organization
Organization Name:DR NELSON R MEDINA, MD C.S.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICO
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEDINA MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-813-2385
Mailing Address - Street 1:PO BOX 332228
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-2228
Mailing Address - Country:US
Mailing Address - Phone:787-813-2385
Mailing Address - Fax:787-984-1691
Practice Address - Street 1:EDIFICIO PORRATA PILA 2431 AVE. LAS AMERICAS
Practice Address - Street 2:SUITE 101
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00731
Practice Address - Country:US
Practice Address - Phone:787-813-2385
Practice Address - Fax:787-984-1691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12324174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1770543514OtherNPI
PRH82130Medicare UPIN
PR1770543514OtherNPI