Provider Demographics
NPI:1679673214
Name:MEDINA, JOSE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:L
Last Name: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 1:5015 N PAULINA ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2756
Mailing Address - Country:US
Mailing Address - Phone:773-775-7540
Mailing Address - Fax:773-763-9792
Practice Address - Street 1:5015 N PAULINA ST
Practice Address - Street 2:SUITE 325
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2756
Practice Address - Country:US
Practice Address - Phone:773-775-7540
Practice Address - Fax:773-763-9792
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC39511Medicare UPIN
IL606140Medicare ID - Type Unspecified