Provider Demographics
NPI:1215977855
Name:MEDINA, ROBERTO M (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:M
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 SILAS DEANE HWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109
Mailing Address - Country:US
Mailing Address - Phone:860-257-4470
Mailing Address - Fax:860-257-4479
Practice Address - Street 1:415 SILAS DEANE HWY
Practice Address - Street 2:SUITE 210
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2124
Practice Address - Country:US
Practice Address - Phone:860-257-4470
Practice Address - Fax:860-257-4479
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT034507174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004220042Medicaid
CTG05318Medicare UPIN
CT004220042Medicaid