Provider Demographics
NPI:1912545187
Name:MEDINA, IVAN J
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:J
Last Name:MEDINA
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:CIUDAD JARDIN III
Mailing Address - Street 2:197 CALLE FLAMBOYAN
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:787-506-8499
Mailing Address - Fax:787-279-4652
Practice Address - Street 1:CIUDAD JARDIN III
Practice Address - Street 2:197 CALLE FLAMBOYAN
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-506-8499
Practice Address - Fax:787-279-4652
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty