1851951024 NPI number — MARIAN DENISSE ORTIZ RODRIGUEZ

Table of content: MARIAN DENISSE ORTIZ RODRIGUEZ (NPI 1851951024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851951024 NPI number — MARIAN DENISSE ORTIZ RODRIGUEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTIZ RODRIGUEZ
Provider First Name:
MARIAN
Provider Middle Name:
DENISSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1851951024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
528 PRESTON PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30096-8817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-204-6112
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3775 VENTURE DR BLDG F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-592-1158
Provider Business Practice Location Address Fax Number:
678-400-0021
Provider Enumeration Date:
06/19/2019

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: 111N00000X , with the licence number:  CHIR010216 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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