Provider Demographics
NPI:1740203660
Name:MEDINA, JENNNYMAR (MD)
Entity Type:Individual
Prefix:
First Name:JENNNYMAR
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
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:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:CASTANER
Mailing Address - State:PR
Mailing Address - Zip Code:00631-0217
Mailing Address - Country:US
Mailing Address - Phone:787-895-4583
Mailing Address - Fax:787-895-4583
Practice Address - Street 1:CARR#2 RAMAL 484
Practice Address - Street 2:BO COCOS
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678
Practice Address - Country:US
Practice Address - Phone:787-895-4583
Practice Address - Fax:787-895-4583
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14968208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0022885Medicare ID - Type Unspecified