Provider Demographics
NPI:1366831703
Name:JOSE GABRIEL MEDINA-SMESTER PA
Entity type:Organization
Organization Name:JOSE GABRIEL MEDINA-SMESTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:MEDINA-SMESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-247-1667
Mailing Address - Street 1:PO BOX 3550
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3550
Mailing Address - Country:US
Mailing Address - Phone:229-247-1667
Mailing Address - Fax:229-245-7661
Practice Address - Street 1:801 BRICKELL AVE STE 954
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-2951
Practice Address - Country:US
Practice Address - Phone:786-375-5098
Practice Address - Fax:229-245-7661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14T5HOtherFLORIDA BLUE