1740491158 NPI number — GUSTAVO ANDRES ORTIZ MD

Table of content: GUSTAVO ANDRES ORTIZ MD (NPI 1740491158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740491158 NPI number — GUSTAVO ANDRES ORTIZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTIZ
Provider First Name:
GUSTAVO
Provider Middle Name:
ANDRES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1740491158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 GALEN DR
Provider Second Line Business Mailing Address:
APT 311E
Provider Business Mailing Address City Name:
KEY BISCAYNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33149-2182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-873-3632
Provider Business Mailing Address Fax Number:
305-585-1899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1611 NW 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33136-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-585-1864
Provider Business Practice Location Address Fax Number:
305-585-1899
Provider Enumeration Date:
05/25/2007

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: 2084N0400X , with the licence number:  TRN5459 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 280243100 . 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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