Provider Demographics
NPI:1548488992
Name:MEDINA, NILTON D (MD)
Entity type:Individual
Prefix:DR
First Name:NILTON
Middle Name:D
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:367 ATHENS HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2207
Mailing Address - Country:US
Mailing Address - Phone:678-466-6760
Mailing Address - Fax:678-802-7094
Practice Address - Street 1:367 ATHENS HWY STE 100
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2207
Practice Address - Country:US
Practice Address - Phone:678-466-6760
Practice Address - Fax:678-802-7094
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA244734208200000X
GA91080208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110086073AMedicaid
MA001728401Medicare PIN