Provider Demographics
NPI:1760664106
Name:MEDINA, MARS ANTONIO (PT)
Entity Type:Individual
Prefix:MR
First Name:MARS
Middle Name:ANTONIO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-1910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 HEMLOCK DR
Practice Address - Street 2:
Practice Address - City:CONGERS
Practice Address - State:NY
Practice Address - Zip Code:10920-1401
Practice Address - Country:US
Practice Address - Phone:845-267-0110
Practice Address - Fax:845-267-2634
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026132-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist