Provider Demographics
NPI:1487796553
Name:MEDINA LOPEZ, ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:MEDINA LOPEZ
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 1:40 CALLE LOPEZ HORMAZABAL
Mailing Address - Street 2:
Mailing Address - City:JUNCOS
Mailing Address - State:PR
Mailing Address - Zip Code:00777-3105
Mailing Address - Country:US
Mailing Address - Phone:787-734-6020
Mailing Address - Fax:787-734-0006
Practice Address - Street 1:CALLE LOPE HORMAZABAL # 40 URB MADRID
Practice Address - Street 2:
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777-0000
Practice Address - Country:US
Practice Address - Phone:787-734-6020
Practice Address - Fax:787-737-0006
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRACAAOther1605232
PRLACRUZ AZUL DE PROther061866
PRHUMANA REFORMAOther7920028
PRAMERICAN HEALTHOther1195
PRGLOBAL HEATLHOther12613083
PRIMCOther7846
PRMMMOther995824
PRPREFERRED HEALTH PLAOther209516
PRTRIPLE SOther20998
PRTRIPLE SOther20998
PRGLOBAL HEATLHOther12613083