Provider Demographics
NPI:1093786444
Name:MEDINA, CARLO (MD)
Entity type:Individual
Prefix:
First Name:CARLO
Middle Name:
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 1:1626 MONTANA AVE # 631
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1808
Mailing Address - Country:US
Mailing Address - Phone:310-823-3443
Mailing Address - Fax:310-305-7470
Practice Address - Street 1:4560 ADMIRALTY WAY STE 201
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5425
Practice Address - Country:US
Practice Address - Phone:310-823-3443
Practice Address - Fax:310-305-7470
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53912208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CAGR0100430OtherGROUP MEDICAL
H76953Medicare UPIN
60S191Medicare ID - Type Unspecified