Provider Demographics
NPI:1508854183
Name:MEDINA, SAFDAR (MD)
Entity Type:Individual
Prefix:
First Name:SAFDAR
Middle Name:
Last Name:MEDINA
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:281 E HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:UXBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01569-1278
Practice Address - Country:US
Practice Address - Phone:508-278-5573
Practice Address - Fax:508-278-7142
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160789208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3205711Medicaid
H09154Medicare UPIN
MA3205711Medicaid