Provider Demographics
NPI:1952871089
Name:MEDINA, ANDRES
Entity type:Individual
Prefix:MR
First Name:ANDRES
Middle Name:
Last Name:MEDINA
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 1:201 CALLE QUENEPA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5129
Mailing Address - Country:US
Mailing Address - Phone:787-399-8208
Mailing Address - Fax:
Practice Address - Street 1:388 ZONA IND REPARADA 2
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2347
Practice Address - Country:US
Practice Address - Phone:787-840-2575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-02
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR36122207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program