Provider Demographics
NPI:1285636894
Name:GOULMAMINE, REDOUANE (MD)
Entity Type:Individual
Prefix:DR
First Name:REDOUANE
Middle Name:
Last Name:GOULMAMINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 HETH CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5532
Mailing Address - Country:US
Mailing Address - Phone:804-897-3455
Mailing Address - Fax:804-504-7795
Practice Address - Street 1:95 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9280
Practice Address - Country:US
Practice Address - Phone:804-504-8100
Practice Address - Fax:804-504-7795
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242555208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA345128OtherANTHEM
VA7047613OtherAETNA
VA3639781OtherCIGNA
VA1285636894Medicaid
VA7047613OtherAETNA