Provider Demographics
NPI:1023112059
Name:ORTIZ, CARLOS IVAN (OD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:IVAN
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4547 TILLMAN BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-0822
Mailing Address - Country:US
Mailing Address - Phone:229-253-8872
Mailing Address - Fax:229-253-0182
Practice Address - Street 1:3274 INNER PERIMETER RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1073
Practice Address - Country:US
Practice Address - Phone:229-253-9530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001470152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist