Provider Demographics
NPI:1356307193
Name:ORELLANA MEDINA, KATHERINE (OD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:ORELLANA MEDINA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9773 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4003
Mailing Address - Country:US
Mailing Address - Phone:954-753-0137
Mailing Address - Fax:954-753-0139
Practice Address - Street 1:9773 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4003
Practice Address - Country:US
Practice Address - Phone:954-753-0137
Practice Address - Fax:954-753-0139
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006221152W00000X
FLOPC3853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000557300Medicaid
NY02072966Medicaid
NYP2390358OtherOXFORD
NYTUV006221OtherHIP
NY6501441OtherGHI
NY6501441OtherGHI
FL000557300Medicaid