Provider Demographics
NPI:1245956184
Name:ROMERO, MIRTHA (COTA)
Entity type:Individual
Prefix:
First Name:MIRTHA
Middle Name:
Last Name:ROMERO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5326 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1304
Mailing Address - Country:US
Mailing Address - Phone:571-319-9178
Mailing Address - Fax:
Practice Address - Street 1:10714 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-2112
Practice Address - Country:US
Practice Address - Phone:240-542-4420
Practice Address - Fax:240-542-4434
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA03073171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA03073OtherCOTA