Provider Demographics
NPI:1023052214
Name:MEDINA, MARISEL (DPM)
Entity type:Individual
Prefix:DR
First Name:MARISEL
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S PINE ISLAND RD
Mailing Address - Street 2:# 300
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3166
Mailing Address - Country:US
Mailing Address - Phone:954-473-6344
Mailing Address - Fax:954-473-8119
Practice Address - Street 1:600 S PINE ISLAND RD
Practice Address - Street 2:# 300
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3166
Practice Address - Country:US
Practice Address - Phone:954-473-6344
Practice Address - Fax:954-473-8119
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3198213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU7105WMedicare PIN
FLV08600Medicare UPIN