Provider Demographics
NPI:1952498867
Name:MEDINA, MANUEL III (PAC)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:MEDINA
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-3621
Mailing Address - Country:US
Mailing Address - Phone:714-541-4090
Mailing Address - Fax:714-541-8815
Practice Address - Street 1:610 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3621
Practice Address - Country:US
Practice Address - Phone:714-541-4090
Practice Address - Fax:714-541-8815
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine