Basic Information
| Provider Information | |||||||||
| NPI: | 1932112679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | JACINTO | ||||||||
| MiddleName: | RENATTO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1945 N FINE STREET | ||||||||
| Address2: | #116 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575807 | ||||||||
| FaxNumber: | 5594575896 | ||||||||
| Practice Location | |||||||||
| Address1: | 2790 S ELM AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937065435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575200 | ||||||||
| FaxNumber: | 5594575290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | A25270 | CA | X | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | A25270 | CA | X | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.