1104897248 NPI number — LEANDRITA F ORTEGA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104897248 NPI number — LEANDRITA F ORTEGA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTEGA
Provider First Name:
LEANDRITA
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104897248
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMOGORDO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88310-6517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-434-5195
Provider Business Mailing Address Fax Number:
575-434-5790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 10TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310-5012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-434-5195
Provider Business Practice Location Address Fax Number:
575-434-5790
Provider Enumeration Date:
01/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  23586 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD2012-0047 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 79805361 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200046270A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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