Provider Demographics
NPI:1497744874
Name:MEDINA, IVAN
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18084 SW 152ND PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-7753
Mailing Address - Country:US
Mailing Address - Phone:305-608-6887
Mailing Address - Fax:
Practice Address - Street 1:15043 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7930
Practice Address - Country:US
Practice Address - Phone:305-238-2474
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15106390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program