Provider Demographics
NPI:1841793957
Name:MEDINA, HUGO (DMS)
Entity Type:Individual
Prefix:
First Name:HUGO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 TENNESSEE ST STE XX
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8163
Mailing Address - Country:US
Mailing Address - Phone:909-570-7175
Mailing Address - Fax:
Practice Address - Street 1:414 TENNESSEE ST STE XX
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8163
Practice Address - Country:US
Practice Address - Phone:909-570-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA962612085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty