Provider Demographics
NPI:1972554954
Name:MEDINA, CARLOS ALFREDO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALFREDO
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 1:8501 WADE BLVD
Mailing Address - Street 2:BLDG. X, SUITE 1020
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-5894
Mailing Address - Country:US
Mailing Address - Phone:972-668-5864
Mailing Address - Fax:972-668-5825
Practice Address - Street 1:8501 WADE BLVD
Practice Address - Street 2:BLDG. X, SUITE 1020
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-5894
Practice Address - Country:US
Practice Address - Phone:972-668-5864
Practice Address - Fax:972-668-5825
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8430208000000X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168602402Medicaid
TX8U3552OtherBLUE CROSS BLUE SHIELD
TX168602401Medicaid
TX8C2651Medicare PIN
TX8U3552OtherBLUE CROSS BLUE SHIELD