Provider Demographics
NPI:1912115858
Name:MEDINA, LUIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:MEDINA
Suffix:
Gender:M
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:N30 CALLE M
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-3133
Mailing Address - Country:US
Mailing Address - Phone:787-760-7405
Mailing Address - Fax:
Practice Address - Street 1:SAN JUAN CITY HOSPITAL
Practice Address - Street 2:MEDICAL CENTER
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936
Practice Address - Country:US
Practice Address - Phone:787-766-0205
Practice Address - Fax:787-767-7011
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5789174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist