Provider Demographics
NPI:1073515250
Name:ORTEGA, TRAVIS G (AUD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:G
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 SW LEE BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505
Mailing Address - Country:US
Mailing Address - Phone:580-531-0022
Mailing Address - Fax:580-531-0026
Practice Address - Street 1:5402 SW LEE BLVD.
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-531-0022
Practice Address - Fax:580-531-0026
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK230237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100669730AMedicaid
OK248509605Medicare ID - Type Unspecified
OK100669730AMedicaid