Provider Demographics
NPI:1669832846
Name:MEDINA, CHRISTOPHER (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:OD
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 24724
Mailing Address - Street 2:
Mailing Address - City:BARRIGADA
Mailing Address - State:GU
Mailing Address - Zip Code:96921-4724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CONCOURSE 4 MICRONESIA MALL
Practice Address - Street 2:IDEAL OPTICAL
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929
Practice Address - Country:US
Practice Address - Phone:671-637-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUOL-029152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management