Healthcare Provider Details

I. General information

NPI: 1598487043
Provider Name (Legal Business Name): ANTHONY MEDINA COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 SW 40TH
OKLAHOMA OK
73109
US

IV. Provider business mailing address

1205 KINGSTON BLVD
EDMOND OK
73034-3227
US

V. Phone/Fax

Practice location:
  • Phone: 405-802-5291
  • Fax:
Mailing address:
  • Phone: 580-318-9415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2274
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: