Provider Demographics
NPI:1528537107
Name:MEDINA, JOSE GERMAN (SA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:GERMAN
Last Name:MEDINA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10881 NW 75TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2206
Mailing Address - Country:US
Mailing Address - Phone:786-477-1159
Mailing Address - Fax:
Practice Address - Street 1:10881 NW 75TH ST
Practice Address - Street 2:
Practice Address - City:MEDLEY
Practice Address - State:FL
Practice Address - Zip Code:33178-2206
Practice Address - Country:US
Practice Address - Phone:786-477-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16-738246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant