Provider Demographics
NPI:1427049972
Name:MEDINA RODRIGUEZ, MIGUEL A (MD)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:MEDINA RODRIGUEZ
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 1:2575 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4126
Mailing Address - Country:US
Mailing Address - Phone:321-454-7148
Mailing Address - Fax:321-449-5015
Practice Address - Street 1:2575 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4126
Practice Address - Country:US
Practice Address - Phone:321-454-7148
Practice Address - Fax:321-449-5015
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12542207Q00000X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD-000Medicare UPIN