Provider Demographics
NPI:1760885180
Name:DR. DODANID CARDONA MEDINA CSP
Entity Type:Organization
Organization Name:DR. DODANID CARDONA MEDINA CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DODANID
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-550-7555
Mailing Address - Street 1:76 VIA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727-3105
Mailing Address - Country:US
Mailing Address - Phone:787-550-7555
Mailing Address - Fax:
Practice Address - Street 1:CENTRO AMBULATORIO HIMMA SAN PABLO CAGUAS PISO G
Practice Address - Street 2:AVE LUIS MUNOZ RIVERA A-1
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-668-7236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15339174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty