Provider Demographics
NPI:1639625783
Name:SOARES MEDINA, ASTRID ROCIO
Entity Type:Individual
Prefix:
First Name:ASTRID ROCIO
Middle Name:
Last Name:SOARES MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E GAY ST UNIT 206
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3169
Mailing Address - Country:US
Mailing Address - Phone:787-717-8477
Mailing Address - Fax:
Practice Address - Street 1:2 CARR PUERTO RICO
Practice Address - Street 2:AV HOSTOS 410 BO SABALOS SUITE 116
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00681-0000
Practice Address - Country:US
Practice Address - Phone:787-381-7469
Practice Address - Fax:787-652-1833
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR196602086S0120X
OH57.0273072086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery