Basic Information
Provider Information | |||||||||
NPI: | 1093852113 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEDINA | ||||||||
FirstName: | TEODORO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MONTANO | ||||||||
OtherFirstName: | TEODORO | ||||||||
OtherMiddleName: | MEDINA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 6675 WESTWOOD BLVD | ||||||||
Address2: | STE 475 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 32821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4078450330 | ||||||||
FaxNumber: | 8889721752 | ||||||||
Practice Location | |||||||||
Address1: | 111 WEBB DR | ||||||||
Address2: |   | ||||||||
City: | DAVENPORT | ||||||||
State: | FL | ||||||||
PostalCode: | 338373962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8634219447 | ||||||||
FaxNumber: | 8634211806 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2007 | ||||||||
LastUpdateDate: | 12/08/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 14489 | PR | N |   | Allopathic & Osteopathic Physicians | General Practice |   | 208D00000X | ACN 793 | FL | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | TW49T | 01 | FL | FL BLUE | OTHER |