Provider Demographics
NPI:1033162300
Name:ORTIZ-DE JESUS', MYRIAM ARACELIS (MD)
Entity Type:Individual
Prefix:
First Name:MYRIAM
Middle Name:ARACELIS
Last Name:ORTIZ-DE JESUS'
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:11424 SULLIVAN RD
Practice Address - Street 2:SUITE B1
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70818-3615
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.09880R208000000X
PR16387208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09479279Medicaid
LA1662330Medicaid
611955Medicare UPIN
MS09479279Medicaid
LA5W245Medicare PIN