Provider Demographics
NPI:1598045981
Name:MEDINA, EDGAR SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:SAMUEL
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:19141 STONE OAK PKWY SUITE 104
Mailing Address - Street 2:PMB 217
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3367
Mailing Address - Country:US
Mailing Address - Phone:210-908-6337
Mailing Address - Fax:855-999-3755
Practice Address - Street 1:401 E SONTERRA BLVD STE 375
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4321
Practice Address - Country:US
Practice Address - Phone:210-908-6337
Practice Address - Fax:855-999-3755
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA1178292084P0800X
TXQ46342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3577181-01Medicaid
TX500933YKSJMedicare PIN