Provider Demographics
NPI:1780854596
Name:OTTO RAUL MEDINILLA SR MD
Entity Type:Organization
Organization Name:OTTO RAUL MEDINILLA SR MD
Other - Org Name:OTTO R MEDINILLA MD FACS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:RAUL
Authorized Official - Last Name:MEDINILLA
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:302-764-8693
Mailing Address - Street 1:110 WELDIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-4710
Mailing Address - Country:US
Mailing Address - Phone:302-764-8693
Mailing Address - Fax:302-764-8693
Practice Address - Street 1:110 WELDIN PARK DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-4710
Practice Address - Country:US
Practice Address - Phone:302-764-8693
Practice Address - Fax:302-764-8693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001897207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B66592Medicare UPIN
G00279Medicare PIN