Provider Demographics
NPI:1194741637
Name:MEDINA, FERNANDO (MD)
Entity type:Individual
Prefix:
First Name:FERNANDO
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 1:8004 NW NORWICK AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-4034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-258-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301500051207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology