Provider Demographics
NPI:1134578859
Name:DE JESUS MEDINA, SANDRA NAIRUBY (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:NAIRUBY
Last Name:DE JESUS MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 N KENDALL DR STE A-211
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1029
Mailing Address - Country:US
Mailing Address - Phone:305-274-2255
Mailing Address - Fax:305-274-2211
Practice Address - Street 1:11400 N KENDALL DR STE A-211
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1029
Practice Address - Country:US
Practice Address - Phone:305-274-2255
Practice Address - Fax:305-274-2211
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME138843208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103773700Medicaid
FL124614200Medicaid