Provider Demographics
NPI:1770525719
Name:MEDINA, EDWARD O (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:O
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 W 26TH AVE STE 400D
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5357
Mailing Address - Country:US
Mailing Address - Phone:303-467-4162
Mailing Address - Fax:303-318-3885
Practice Address - Street 1:1960 OGDEN ST STE 550
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1022
Practice Address - Country:US
Practice Address - Phone:303-318-2600
Practice Address - Fax:303-318-2604
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43760208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92572324Medicaid
P00297512OtherMEDICARE RAILROAD
P00297512OtherMEDICARE RAILROAD
COC803664Medicare PIN