Provider Demographics
NPI:1679671572
Name:MEDINA, MIGUEL (ITDS)
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17615 FRANJO RD
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5636
Mailing Address - Country:US
Mailing Address - Phone:786-268-2611
Mailing Address - Fax:
Practice Address - Street 1:17615 FRANJO RD
Practice Address - Street 2:
Practice Address - City:VILLAGE OF PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5636
Practice Address - Country:US
Practice Address - Phone:786-268-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist