Provider Demographics
NPI:1073035390
Name:SURILLO-ORTIZ, SORIVETTE (MD)
Entity Type:Individual
Prefix:
First Name:SORIVETTE
Middle Name:
Last Name:SURILLO-ORTIZ
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:PMB #238 PO BOX 4960
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-4960
Mailing Address - Country:US
Mailing Address - Phone:787-236-2422
Mailing Address - Fax:
Practice Address - Street 1:AVE EL JIBARO CARR #172 KM 13.5 BO BAYAMON
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739-3714
Practice Address - Country:US
Practice Address - Phone:787-739-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125071436OtherSTATE LICENSE NUMBER