Provider Demographics
NPI:1831352293
Name:OMAR F MEDINA-MARENCO DO PA
Entity type:Organization
Organization Name:OMAR F MEDINA-MARENCO DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:F
Authorized Official - Last Name:MEDINA-MARENCO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-510-2586
Mailing Address - Street 1:PO BOX 831419
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33283-1419
Mailing Address - Country:US
Mailing Address - Phone:305-510-2586
Mailing Address - Fax:
Practice Address - Street 1:1898 SW 27TH AVE
Practice Address - Street 2:SUITE # 1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2445
Practice Address - Country:US
Practice Address - Phone:305-447-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9040207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty