Provider Demographics
NPI:1417798158
Name:MEDINA, FABIOLA
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6502 MCMAHAN DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573
Mailing Address - Country:US
Mailing Address - Phone:713-397-3436
Mailing Address - Fax:
Practice Address - Street 1:UTMB GME C/O E ESPINO 301 UNIVERSITY BLVD 5.138 RS
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0001
Practice Address - Country:US
Practice Address - Phone:713-397-3436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10089980208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics