1316966468 NPI number — DIMARY ORTIZ MENDEZ I MD

Table of content: DIMARY ORTIZ MENDEZ I MD (NPI 1316966468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316966468 NPI number — DIMARY ORTIZ MENDEZ I MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTIZ MENDEZ
Provider First Name:
DIMARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
I
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:
1316966468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
49 CARR 307 APARTADO 108
Provider Second Line Business Mailing Address:
EDIFICIOS OLAS A8, CABOQUERON RESORT
Provider Business Mailing Address City Name:
BOQUERON
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00622-9768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-249-5062
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 AVE. HOSTOS , STE. 311, COND. MEDICAL CENTER PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYAGUEZ
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00682-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-249-5062
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2006

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: 208D00000X , with the licence number:  ACN558 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 14094 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DD319A . This is a "PTAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: HS203A . This is a "PTAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 141306000114-001 . This is a "CCN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 108805300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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