Healthcare Provider Details

I. General information

NPI: 1356311161
Provider Name (Legal Business Name): BETH ANN OMUNDSEN-OTT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SELMA DR
WINCHESTER VA
22601-3834
US

IV. Provider business mailing address

104 SELMA DR
WINCHESTER VA
22601-3834
US

V. Phone/Fax

Practice location:
  • Phone: 540-678-2800
  • Fax: 540-678-2859
Mailing address:
  • Phone: 540-678-2800
  • Fax: 540-678-2859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101044204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: