Provider Demographics
NPI:1285014845
Name:ORTA, ANDY (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:
Last Name:ORTA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7482 CENTER ST UNIT 100
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5847
Mailing Address - Country:US
Mailing Address - Phone:440-357-8418
Mailing Address - Fax:440-255-9400
Practice Address - Street 1:7482 CENTER ST UNIT 100
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-357-8418
Practice Address - Fax:440-255-9400
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH36003885213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH030260Medicaid