Provider Demographics
NPI:1669919171
Name:MEDINA HONDAL, IDALIS
Entity type:Individual
Prefix:
First Name:IDALIS
Middle Name:
Last Name:MEDINA HONDAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14439 SW 126TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7405
Mailing Address - Country:US
Mailing Address - Phone:786-237-9605
Mailing Address - Fax:
Practice Address - Street 1:311 NE 8TH ST
Practice Address - Street 2:SUIT 104
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4738
Practice Address - Country:US
Practice Address - Phone:305-248-8600
Practice Address - Fax:184-427-2815
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-22
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27215225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant