Provider Demographics
NPI:1467747659
Name:MEDINA CARBONELL, FERNANDO RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:RAFAEL
Last Name:MEDINA CARBONELL
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 1:1465 S GRAND BLVD, DEPT OF PEDIATRICS
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-268-4010
Mailing Address - Fax:314-268-2775
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-268-4010
Practice Address - Fax:314-268-2775
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE299382080P0206X
MO20200015322080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology