Provider Demographics
NPI:1730227125
Name:MEDINA, CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:MEDINA
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 1:525 E 68TH ST # 94
Mailing Address - Street 2:DEPARTMENT OF PEDIATRIC UROLOGY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:212-746-5361
Mailing Address - Fax:121-746-8065
Practice Address - Street 1:525 E 68TH ST # 94
Practice Address - Street 2:DEPARTMENT OF PEDIATRIC UROLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-5361
Practice Address - Fax:121-746-8065
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429306208800000X
NY247542-1208800000X
NY2475422088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGMedicaid
PENDINGMedicare UPIN
PAPENDINGMedicaid