Provider Demographics
NPI:1083336630
Name:MEDINA, OMAR (COTAL)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 APPLEFORD DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7091
Mailing Address - Country:US
Mailing Address - Phone:804-937-4096
Mailing Address - Fax:
Practice Address - Street 1:235 DUNLOP FARMS BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1792
Practice Address - Country:US
Practice Address - Phone:804-937-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002-093224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant