Provider Demographics
NPI:1295784007
Name:ONTIVEROS, JORGE ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ANTONIO
Last Name:ONTIVEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13709 S SANTA FE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7327
Mailing Address - Country:US
Mailing Address - Phone:405-794-4474
Mailing Address - Fax:888-440-5383
Practice Address - Street 1:13709 S SANTA FE AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-7327
Practice Address - Country:US
Practice Address - Phone:405-794-4484
Practice Address - Fax:888-440-5383
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7852207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F1299Medicare ID - Type Unspecified
TXHO 4561Medicare UPIN