Provider Demographics
NPI:1700937299
Name:MEDINA, JOYCE BENAVIDES (OD)
Entity Type:Individual
Prefix:DR
First Name:JOYCE
Middle Name:BENAVIDES
Last Name:MEDINA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JOYCE
Other - Middle Name:OASAY
Other - Last Name:BENEVIDES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1010 UNIVERSITY AVENUE
Mailing Address - Street 2:SUITE C109
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-955-5369
Mailing Address - Fax:619-329-4369
Practice Address - Street 1:1010 UNIVERSITY AVENUE
Practice Address - Street 2:SUITE C109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-955-5369
Practice Address - Fax:619-329-4369
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10675T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN-SD0106750Medicare ID - Type Unspecified
CAU62750Medicare UPIN