Provider Demographics
NPI:1770543514
Name:MEDINA, NELSON R (MD)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:R
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NELSON
Other - Middle Name:R
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P O BOX 332228
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-2228
Mailing Address - Country:US
Mailing Address - Phone:787-813-2385
Mailing Address - Fax:787-984-1691
Practice Address - Street 1:311 TORRE SAN CRISTOBAL
Practice Address - Street 2:
Practice Address - City:COTO LAUREL
Practice Address - State:PR
Practice Address - Zip Code:00780-2856
Practice Address - Country:US
Practice Address - Phone:787-813-2385
Practice Address - Fax:787-984-1691
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12324207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR037630002Medicaid
PR403255022OtherPROSAM
PR600932OtherMEDICARE Y MUCHO MAS
PR09312324OtherGLOBAL HEATH
PR214131OtherPREFERRED MEDICAL
PR3561OtherFISRT MEDICAL
PR1808OtherPREFERRED MEDICAL CHOICE
PR5012324OtherAUTORIDAD DE ACUEDUCTOS
PRSE4203OtherPALIC
PR061067OtherCRUZ AZUL DE PR
PR89966Medicare ID - Type Unspecified