Provider Demographics
NPI:1922005701
Name:MEDINA, MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
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 1:1801 AVE PONCE DE LEON
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909-1900
Mailing Address - Country:US
Mailing Address - Phone:787-268-3192
Mailing Address - Fax:787-268-3191
Practice Address - Street 1:1801 AVE PONCE DE LEON
Practice Address - Street 2:SUITE 304
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-1900
Practice Address - Country:US
Practice Address - Phone:787-268-3192
Practice Address - Fax:787-268-3191
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR67832086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD32330Medicare UPIN
PR29482Medicare ID - Type Unspecified