Provider Demographics
NPI:1770834665
Name:MEDINA, IMMANUEL KARLO GALLETA (PT)
Entity Type:Individual
Prefix:MR
First Name:IMMANUEL KARLO
Middle Name:GALLETA
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 1:8758 WELLES EDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-2115
Mailing Address - Country:US
Mailing Address - Phone:408-449-8150
Mailing Address - Fax:
Practice Address - Street 1:8758 WELLES EDGE DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240
Practice Address - Country:US
Practice Address - Phone:408-449-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12177532251X0800X
CA299318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36289166OtherDMV