Basic Information
| Provider Information | |||||||||
| NPI: | 1184889271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA CARCAMO | ||||||||
| FirstName: | EDWING | ||||||||
| MiddleName: | GERARDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CAPITAL WAY | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085342520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093034000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 750 BRUNSWICK AVE | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086384143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093946000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | 25MA08361900 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207R00000X | 25MA08361900 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0195901 | 05 | NJ | MEDICAID |