Provider Demographics
NPI:1457690588
Name:MEDINA, ROBERTO SANTOS (PT)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:SANTOS
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 N WICKHAM RD APT 614
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2354
Mailing Address - Country:US
Mailing Address - Phone:321-890-4223
Mailing Address - Fax:
Practice Address - Street 1:3033 SARNO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7229
Practice Address - Country:US
Practice Address - Phone:321-242-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-09
Last Update Date:2013-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist