Provider Demographics
NPI:1598487043
Name:MEDINA, ANTHONY (COTA/L)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 KINGSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3227
Mailing Address - Country:US
Mailing Address - Phone:580-318-9415
Mailing Address - Fax:
Practice Address - Street 1:729 SW 40TH
Practice Address - Street 2:
Practice Address - City:OKLAHOMA
Practice Address - State:OK
Practice Address - Zip Code:73109
Practice Address - Country:US
Practice Address - Phone:405-802-5291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2274225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK062021131991010219Medicaid