Provider Demographics
NPI:1780714873
Name:AMARO MEDINA, MIRNA SOCORRO (MD)
Entity type:Individual
Prefix:DR
First Name:MIRNA
Middle Name:SOCORRO
Last Name:AMARO MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29454
Mailing Address - Street 2:65TH INFANTRY STATION
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00929-0454
Mailing Address - Country:US
Mailing Address - Phone:787-768-6996
Mailing Address - Fax:787-768-6996
Practice Address - Street 1:893 CALLE EIDER
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-2371
Practice Address - Country:US
Practice Address - Phone:787-768-6996
Practice Address - Fax:787-768-6996
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10297208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty