Provider Demographics
NPI:1720733710
Name:MEDINA ORTA, ANGEL LUIS
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:LUIS
Last Name:MEDINA ORTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB SANTA CLARA CALLE 5 #222
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754-9998
Mailing Address - Country:US
Mailing Address - Phone:787-672-8753
Mailing Address - Fax:
Practice Address - Street 1:URB SANTA CLARA CALLE 5 #222
Practice Address - Street 2:
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754-9998
Practice Address - Country:US
Practice Address - Phone:787-672-8753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22601208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty