Provider Demographics
NPI:1235270372
Name:ORTOLANO, EDNA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:MARIE
Last Name:ORTOLANO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 BELL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-2401
Mailing Address - Country:US
Mailing Address - Phone:954-540-0572
Mailing Address - Fax:
Practice Address - Street 1:15575 NW 12TH PL
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1617
Practice Address - Country:US
Practice Address - Phone:954-447-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3259152W00000X
TX9232T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620406601Medicaid
FL620406601Medicaid