Provider Demographics
NPI:1710048228
Name:MEDINA, CARLOS A (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
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 1:500 E OGLETHORPE HWY
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2804
Mailing Address - Country:US
Mailing Address - Phone:843-577-5011
Mailing Address - Fax:
Practice Address - Street 1:500 E OGLETHORPE HWY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2804
Practice Address - Country:US
Practice Address - Phone:843-577-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00986172Medicaid
NY00986172Medicaid