Provider Demographics
NPI:1588768733
Name:MARISEL MEDINA DPM PA
Entity type:Organization
Organization Name:MARISEL MEDINA DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARISEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-317-8037
Mailing Address - Street 1:11930 N BAYSHORE DR
Mailing Address - Street 2:APT 310
Mailing Address - City:N MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181
Mailing Address - Country:US
Mailing Address - Phone:786-317-8033
Mailing Address - Fax:305-891-7324
Practice Address - Street 1:11760 SW 40TH ST
Practice Address - Street 2:STE H 451
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175
Practice Address - Country:US
Practice Address - Phone:786-317-8033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-09
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP03198213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K9550Medicare PIN
U08600Medicare UPIN