Provider Demographics
NPI:1932134020
Name:MEDINA, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
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 1:1776 WOODSTEAD CT STE 208
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1480
Mailing Address - Country:US
Mailing Address - Phone:877-749-7428
Mailing Address - Fax:512-628-3314
Practice Address - Street 1:130 MOORINGS PARK DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34105-2122
Practice Address - Country:US
Practice Address - Phone:877-749-7428
Practice Address - Fax:512-628-3314
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92091208100000X, 208100000X, 2081P0004X, 2081P2900X, 2081S0010X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28517OtherBCBS GROUP NO.
FLK7129Medicare ID - Type UnspecifiedMEDICARE GROUP NO.
FLI25110Medicare UPIN
FL01025ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.