Provider Demographics
NPI:1336163179
Name:MEDINA, WALTER ANDREW SR (DO)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:ANDREW
Last Name:MEDINA
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6370 110TH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1440
Mailing Address - Country:US
Mailing Address - Phone:718-833-8052
Mailing Address - Fax:718-833-8968
Practice Address - Street 1:6370 110TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1440
Practice Address - Country:US
Practice Address - Phone:718-833-8052
Practice Address - Fax:718-833-8968
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206169208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01744632Medicaid
NY86Y561Medicare ID - Type Unspecified
NY01744632Medicaid
NYG61083Medicare UPIN