Provider Demographics
NPI:1083732283
Name:MEDINA, VICTOR (MA OTR)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MA OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 PRIMROSE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-2873
Mailing Address - Country:US
Mailing Address - Phone:310-871-7443
Mailing Address - Fax:
Practice Address - Street 1:4655 RUFFNER ST
Practice Address - Street 2:STE 270
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2275
Practice Address - Country:US
Practice Address - Phone:180-078-7678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6030225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist