Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 29919 | OK |
N | 207P00000X | Emergency Physician | 311630 | LA |
N | 207Q00000X | Family Doctor | BP10045433 | TX |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 29919 | OK |
N | 207RG0300X | Geriatric Medicine | BP10045433 | TX |
NPI | 1063850147 |
---|---|
Provider Name | Dr. Roberto Eduardo Medina |
First Address | Monroe, LA 71201-7407 |
Second Address | Monroe, LA 71201-7407 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2013 |
Last Update Date | 20/04/2021 |