Provider Demographics
NPI:1518031715
Name:MEDINA, ROLDAN G (MD031273)
Entity Type:Individual
Prefix:DR
First Name:ROLDAN
Middle Name:G
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD031273
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CONNELLSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-3848
Mailing Address - Country:US
Mailing Address - Phone:724-439-2050
Mailing Address - Fax:724-439-0793
Practice Address - Street 1:60 CONNELLSVILLE ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-3848
Practice Address - Country:US
Practice Address - Phone:724-439-2050
Practice Address - Fax:724-439-0793
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC28166Medicare UPIN
PA032712Medicare ID - Type Unspecified