Provider Demographics
NPI:1053584011
Name:MIGUEL A MEDINA MD PA
Entity type:Organization
Organization Name:MIGUEL A MEDINA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-268-6111
Mailing Address - Street 1:119 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3377
Mailing Address - Country:US
Mailing Address - Phone:321-264-8644
Mailing Address - Fax:321-264-8933
Practice Address - Street 1:119 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3377
Practice Address - Country:US
Practice Address - Phone:321-264-8644
Practice Address - Fax:321-264-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0097000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME97000OtherSTATE LICENSE