Provider Demographics
NPI:1720844905
Name:MEDINA, GABRIEL ANTONIO (RD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ANTONIO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 SAVANNAH RIVER WAY APT 313
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-5070
Mailing Address - Country:US
Mailing Address - Phone:407-922-9903
Mailing Address - Fax:
Practice Address - Street 1:5004 SAVANNAH RIVER WAY APT 313
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-5070
Practice Address - Country:US
Practice Address - Phone:407-922-9903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL086295766133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist