Provider Demographics
NPI:1518030402
Name:MEDINA, CHRISTOPHER CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:CARLOS
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 1:1001 W FAYETTE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2866
Mailing Address - Country:US
Mailing Address - Phone:315-937-3433
Mailing Address - Fax:
Practice Address - Street 1:5800 HERITAGE LANDING DR STE C
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9378
Practice Address - Country:US
Practice Address - Phone:315-445-2701
Practice Address - Fax:315-445-2847
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241815207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03450039Medicaid
NYJ400071144Medicare PIN