Provider Demographics
NPI:1821551748
Name:MEDINA, JOSE SEBASTIAN (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:SEBASTIAN
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-7003
Mailing Address - Country:US
Mailing Address - Phone:213-419-9600
Mailing Address - Fax:213-419-9900
Practice Address - Street 1:1414 S GRAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3072
Practice Address - Country:US
Practice Address - Phone:213-419-9600
Practice Address - Fax:213-419-9900
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA184665207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program