Provider Demographics
NPI:1629684733
Name:MEDINA RUIZ, JUAN A SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:A
Last Name:MEDINA RUIZ
Suffix:SR
Gender:M
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:PO BOX 10007 SUITE 420
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-4007
Mailing Address - Country:US
Mailing Address - Phone:787-204-4372
Mailing Address - Fax:
Practice Address - Street 1:CONDOMINIO GUAMANI GARDENS CARR 179 H.0 BARRIO GUAMANI
Practice Address - Street 2:APT 7
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784-0000
Practice Address - Country:US
Practice Address - Phone:787-204-4372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21988208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice