Provider Demographics
NPI:1952948093
Name:MEDINA, RICHARD A
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
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 1:2976 NORTHERN BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-2829
Mailing Address - Country:US
Mailing Address - Phone:212-691-7554
Mailing Address - Fax:347-510-3457
Practice Address - Street 1:2976 NORTHERN BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2829
Practice Address - Country:US
Practice Address - Phone:212-691-7554
Practice Address - Fax:347-510-3457
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCRPA-1891175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist