Provider Demographics
NPI: | 1598152571 |
---|---|
Name: | MEDINA AVILES, SHARLENE (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SHARLENE |
Middle Name: | |
Last Name: | MEDINA AVILES |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 270 CALLE LA CANDELARIA |
Mailing Address - Street 2: | PO BOX 8095 |
Mailing Address - City: | MAYAGUEZ |
Mailing Address - State: | PR |
Mailing Address - Zip Code: | 00681-2116 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 787-455-0498 |
Mailing Address - Fax: | |
Practice Address - Street 1: | EDIFICIO PARRA SUITE 1003 |
Practice Address - Street 2: | 2213 PONCE BYPASS |
Practice Address - City: | PONCE |
Practice Address - State: | PR |
Practice Address - Zip Code: | 00717 |
Practice Address - Country: | US |
Practice Address - Phone: | 787-455-0498 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2015-04-17 |
Last Update Date: | 2022-09-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PR | 19657 | 207R00000X, 207RI0011X |
PR | 32609 | 390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
Yes | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |