1275743684 NPI number — LISA D ORTIZ M.D.

Table of content: LISA D ORTIZ M.D. (NPI 1275743684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275743684 NPI number — LISA D ORTIZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTIZ
Provider First Name:
LISA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1275743684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1483 DEER RUN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT GIBSON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74434-9351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-478-2267
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 J T STITES BLVD
Provider Second Line Business Practice Location Address:
REDBIRD SMITH HEALTH CENTER
Provider Business Practice Location Address City Name:
SALLISAW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74955-9302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-775-9159
Provider Business Practice Location Address Fax Number:
918-775-6469
Provider Enumeration Date:
05/23/2007

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: 207R00000X , with the licence number:  25970 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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