Provider Demographics
NPI:1558627802
Name:FARIN-MEDINA, LEONARDO LEWIS
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:LEWIS
Last Name:FARIN-MEDINA
Suffix:
Gender:M
Credentials:
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 159
Mailing Address - Street 2:NAVAL SUBMARINE BASE, NEW LONDON
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5159
Mailing Address - Country:US
Mailing Address - Phone:860-964-2876
Mailing Address - Fax:
Practice Address - Street 1:159 TROUT AVE, BLDG. 86
Practice Address - Street 2:NUMI, NAVAL SUBMARINE BASE, NEW LONDON
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5159
Practice Address - Country:US
Practice Address - Phone:860-694-2876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman