Provider Demographics
NPI:1841256203
Name:MEDINA DE JESUS, ERNESTO (MD)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:MEDINA DE JESUS
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 1:62 CALLE MENDEZ ALVAREZ
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754-3537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:62 CALLE MENDEZ ALVAREZ
Practice Address - Street 2:
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754-3537
Practice Address - Country:US
Practice Address - Phone:787-736-6359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14975208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH96913Medicare UPIN
22068Medicare ID - Type Unspecified