Provider Demographics
NPI:1750948899
Name:MEDINA, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2503
Mailing Address - Country:US
Mailing Address - Phone:650-393-8965
Mailing Address - Fax:
Practice Address - Street 1:1410 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2503
Practice Address - Country:US
Practice Address - Phone:650-393-8965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X, 373H00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist