Provider Demographics
NPI:1194791129
Name:MEDINA, ANGELA M (OD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:M
Last Name:MEDINA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:D7 CALLE TULANE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-4905
Mailing Address - Country:US
Mailing Address - Phone:787-617-7821
Mailing Address - Fax:
Practice Address - Street 1:PEARLE VISION PLAZA LAS AMERICAS
Practice Address - Street 2:LOCAL 140
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-753-1033
Practice Address - Fax:787-758-1494
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist