Provider Demographics
NPI:1265826226
Name:ORTIZ, MARIO REMEDIOS (PHD; PHCNS-BC, FNP-C)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:REMEDIOS
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PHD; PHCNS-BC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MISHAWAKA AVE # SAC-130
Mailing Address - Street 2:HEALTH & WELLNESS CENTER, IU SOUTH BEND
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-1408
Mailing Address - Country:US
Mailing Address - Phone:574-520-5557
Mailing Address - Fax:574-520-5042
Practice Address - Street 1:1700 MISHAWAKA AVE # SAC-130
Practice Address - Street 2:HEALTH & WELLNESS CENTER, IU SOUTH BEND
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1408
Practice Address - Country:US
Practice Address - Phone:574-520-5557
Practice Address - Fax:574-520-5042
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005395A363LF0000X, 364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily