Provider Demographics
NPI:1508252461
Name:MEDALLA, AILENE D (MD)
Entity Type:Individual
Prefix:
First Name:AILENE
Middle Name:D
Last Name:MEDALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AILENE
Other - Middle Name:
Other - Last Name:DUMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:725 VOLVO PKWY STE 100
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-548-0076
Practice Address - Fax:757-548-1652
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101264734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program