Provider Demographics
NPI:1649259540
Name:MEDINILLA, OTTO R JR (PAC)
Entity type:Individual
Prefix:MR
First Name:OTTO
Middle Name:R
Last Name:MEDINILLA
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3048
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:302-224-5678
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:11300 LINDBERGH BLVD STE 115
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8827
Practice Address - Country:US
Practice Address - Phone:239-245-8600
Practice Address - Fax:239-245-8660
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000036903Medicaid
S58291Medicare UPIN
DE001415D04Medicare ID - Type Unspecified