Provider Demographics
NPI:1497853568
Name:MEDINA, JUAN R (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:R
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 W LACEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5906
Mailing Address - Country:US
Mailing Address - Phone:559-583-4617
Mailing Address - Fax:559-583-4625
Practice Address - Street 1:1310 HANNA AVE
Practice Address - Street 2:STE 1
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212-2314
Practice Address - Country:US
Practice Address - Phone:559-992-3300
Practice Address - Fax:559-992-8162
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAF73385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G728880Medicaid
CA00G728880Medicare ID - Type Unspecified
CAF73385Medicare UPIN