Provider Demographics
NPI:1477669034
Name:MEDINA, IRMA (MD)
Entity Type:Individual
Prefix:DR
First Name:IRMA
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 1:11335 SSG SIMS
Mailing Address - Street 2:
Mailing Address - City:FT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918
Mailing Address - Country:US
Mailing Address - Phone:915-742-2273
Mailing Address - Fax:
Practice Address - Street 1:11335 SSG SIMS
Practice Address - Street 2:
Practice Address - City:FT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918
Practice Address - Country:US
Practice Address - Phone:915-742-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0867208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101871501Medicaid
TX89613XOtherBC/BS OF TEXAS
TX8146J6Medicare ID - Type Unspecified