=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679294201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMA HEALTH PLAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2022
-----------------------------------------------------
Last Update Date | 09/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 S MAIN ST
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23523-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-388-1830
-----------------------------------------------------
Fax | 855-939-7176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 S MAIN ST
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23523-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-388-1830
-----------------------------------------------------
Fax | 855-939-7176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DORIS PRINCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-983-5475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------