Provider Demographics
NPI:1124010582
Name:MEDINA, MA LUCIA CANADA (MD)
Entity type:Individual
Prefix:DR
First Name:MA LUCIA
Middle Name:CANADA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MA LUCIA
Other - Middle Name:
Other - Last Name:CANADA MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6070
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-6070
Mailing Address - Country:US
Mailing Address - Phone:361-853-3222
Mailing Address - Fax:361-561-2681
Practice Address - Street 1:5945 SARATOGA BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4225
Practice Address - Country:US
Practice Address - Phone:361-853-3222
Practice Address - Fax:361-980-3619
Is Sole Proprietor?:No
Enumeration Date:2005-08-21
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0930208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110645202Medicaid