Provider Demographics
NPI:1629502463
Name:ORTIZ, PEDRO
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 S WOODLAND BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7464
Mailing Address - Country:US
Mailing Address - Phone:386-202-6025
Mailing Address - Fax:
Practice Address - Street 1:1200 DELTONA BLVD APT 40A
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-6386
Practice Address - Country:US
Practice Address - Phone:386-202-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR008557247200000X
FLPA9119021363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9119021OtherMEDICAL LICENSE
205411OtherREGISTRY NUMBER