Provider Demographics
NPI:1760635106
Name:MEDINA, DORIS G (LND,RD)
Entity Type:Individual
Prefix:MS
First Name:DORIS
Middle Name:G
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LND,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 CALLE JUAN KEPLER
Mailing Address - Street 2:URB.TULIPAN
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-4431
Mailing Address - Country:US
Mailing Address - Phone:787-777-3535
Mailing Address - Fax:787-756-8907
Practice Address - Street 1:480 CALLE JUAN KEPLER
Practice Address - Street 2:URB.TULIPAN
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-4431
Practice Address - Country:US
Practice Address - Phone:787-777-3535
Practice Address - Fax:787-756-8907
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR684133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered