Provider Demographics
NPI:1194582536
Name:MEDINA CORDOBA, MATEO ANDRES (SA-C)
Entity type:Individual
Prefix:
First Name:MATEO
Middle Name:ANDRES
Last Name:MEDINA CORDOBA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13960 SW 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6453
Mailing Address - Country:US
Mailing Address - Phone:561-690-8086
Mailing Address - Fax:
Practice Address - Street 1:13960 SW 160TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-6453
Practice Address - Country:US
Practice Address - Phone:561-690-8086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-182246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant