Provider Demographics
NPI:1063976116
Name:MEDINA MORELL, JUAN R
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:R
Last Name:MEDINA MORELL
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:PO BOX 79191
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984-9191
Mailing Address - Country:US
Mailing Address - Phone:829-717-8822
Mailing Address - Fax:
Practice Address - Street 1:1008 AVE AMERICO MIRANDA
Practice Address - Street 2:
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00921-2842
Practice Address - Country:US
Practice Address - Phone:829-717-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR15480-I208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program