Provider Demographics
NPI:1104227503
Name:DULA, OMAR ANGELO
Entity type:Individual
Prefix:MR
First Name:OMAR ANGELO
Middle Name:
Last Name:DULA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ANGELO
Other - Middle Name:
Other - Last Name:DULA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2855 FOOTHILL BLVD
Mailing Address - Street 2:K202
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3100
Mailing Address - Country:US
Mailing Address - Phone:646-306-1402
Mailing Address - Fax:
Practice Address - Street 1:2855 FOOTHILL BLVD
Practice Address - Street 2:K202
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3100
Practice Address - Country:US
Practice Address - Phone:646-306-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst