Provider Demographics
NPI:1528547999
Name:DR CONSTATINO MEDIETA
Entity Type:Organization
Organization Name:DR CONSTATINO MEDIETA
Other - Org Name:DR. CONSTATINO MEDIETA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONSTATINO
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDIETA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-529-9237
Mailing Address - Street 1:2310 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2314
Mailing Address - Country:US
Mailing Address - Phone:310-529-9237
Mailing Address - Fax:626-331-3204
Practice Address - Street 1:2310 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-2314
Practice Address - Country:US
Practice Address - Phone:310-529-9237
Practice Address - Fax:626-331-3204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL070055208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty