Provider Demographics
NPI:1790016160
Name:MEDINA VILLANUEVA, NELSON
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:MEDINA VILLANUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LYONS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2027
Mailing Address - Country:US
Mailing Address - Phone:973-926-6639
Mailing Address - Fax:
Practice Address - Street 1:2940 MALLORY CIR STE 204
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-1818
Practice Address - Country:US
Practice Address - Phone:407-507-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17747207R00000X
FLME119501207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty