Provider Demographics
NPI:1053301499
Name:ORTIZ-EVANS, ILEANA (MD)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:ORTIZ-EVANS
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:PO BOX 758952
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8952
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:1205 US ROUTE 22
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865
Practice Address - Country:US
Practice Address - Phone:908-213-2211
Practice Address - Fax:908-213-9913
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071288L207Q00000X
NJMA68294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8313407Medicaid
PA119772OtherMEDICARE PA
PA508842YUNMMedicare PIN
NJ8313407Medicaid
PA508842YEBKMedicare PIN