Provider Demographics
NPI:1699080531
Name:MEDINA-NAVARRO, JOSE MANUEL (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:MEDINA-NAVARRO
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 1:1650 SELWYN AVE APT 4A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7628
Mailing Address - Country:US
Mailing Address - Phone:718-960-1216
Mailing Address - Fax:
Practice Address - Street 1:1650 SELWYN AVE APT 4A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7628
Practice Address - Country:US
Practice Address - Phone:718-960-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699080531OtherRESIDENCY PROGRAM