Provider Demographics
NPI:1760416291
Name:MEDINA-AGOSTINI, ISMAEL (MD)
Entity Type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:MEDINA-AGOSTINI
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 1:301 J.H. CINTRON ST
Mailing Address - Street 2:ESTANCIAS DEL GOLF CLUB
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730
Mailing Address - Country:US
Mailing Address - Phone:787-284-5682
Mailing Address - Fax:787-284-5682
Practice Address - Street 1:43 AVE SEVERIANO CUEVAS
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5766
Practice Address - Country:US
Practice Address - Phone:787-891-4865
Practice Address - Fax:787-891-4865
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12886208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice