Individual
JORGE MEDINA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4500 W 181ST AVE, LOWELL, IN 46356-0017
(219) 690-2016
(219) 690-1862
Mailing address
PO BOX 781076, DETROIT, MI 48278-7241
(317) 528-4800
(317) 865-1479
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
01061849A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000722508
ANTHEM TRADITIONAL
IN
05
—
200825470
—
IN
Enumeration date
06/01/2006
Last updated
10/11/2023
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