Provider Demographics
NPI:1376868281
Name:MEDINA, DANIEL C (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:C
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 1:2400 PINE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401
Mailing Address - Country:US
Mailing Address - Phone:715-847-2022
Mailing Address - Fax:715-843-1220
Practice Address - Street 1:SURGICAL ASSOCIATES, SC
Practice Address - Street 2:2400 PINE RIDGE BLVD
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-847-2022
Practice Address - Fax:715-843-1220
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-1942208600000X
WI1924-320208600000X
PAMD456117208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery