Provider Demographics
NPI:1639408586
Name:BRICENO-MEDINA, MARIO E (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:E
Last Name:BRICENO-MEDINA
Suffix:
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 1:1432 ISLAND TOWN DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-9045
Mailing Address - Country:US
Mailing Address - Phone:901-483-7886
Mailing Address - Fax:
Practice Address - Street 1:51 N DUNLAP ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4625
Practice Address - Country:US
Practice Address - Phone:901-287-7337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN543342080P0202X
MI43011035022080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology