Provider Demographics
NPI:1669561718
Name:MEDINA, FERNANDO (DR)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CB-6, EUCALIPTO ST., RIOHONDO III,
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-384-4013
Mailing Address - Fax:787-785-3985
Practice Address - Street 1:CONDOMINIO LAS TORRES,
Practice Address - Street 2:SUITE 6E, TORRE SUR
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-384-4013
Practice Address - Fax:787-785-3985
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical