Provider Demographics
NPI:1225100308
Name:ORTIZ, JUAN ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ANTONIO
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:ANTONIO
Other - Last Name:ORTIZ PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD FACS
Mailing Address - Street 1:9104 FALLS OF NEUSE RD
Mailing Address - Street 2:STE 204
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-2493
Mailing Address - Country:US
Mailing Address - Phone:919-706-4909
Mailing Address - Fax:919-706-4901
Practice Address - Street 1:9104 FALLS OF NEUSE RD
Practice Address - Street 2:STE 204
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2493
Practice Address - Country:US
Practice Address - Phone:919-706-4900
Practice Address - Fax:919-706-4901
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-005552086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery