Provider Demographics
NPI:1982684924
Name:MEDINA, HERNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HERNAN
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 1:9590 E IRONWOOD SQUARE DR
Mailing Address - Street 2:STE 125
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4583
Mailing Address - Country:US
Mailing Address - Phone:480-455-3000
Mailing Address - Fax:866-819-6115
Practice Address - Street 1:6838 N 23RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015
Practice Address - Country:US
Practice Address - Phone:602-864-8800
Practice Address - Fax:602-864-1448
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30853174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH78947Medicare UPIN
AZ754045Medicare ID - Type Unspecified
AZZ79530Medicare ID - Type Unspecified