Provider Demographics
NPI:1306187570
Name:VELA-ORTIZ, MYRIAM C (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRIAM
Middle Name:C
Last Name:VELA-ORTIZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 CLINIC AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4454
Mailing Address - Country:US
Mailing Address - Phone:770-832-0429
Mailing Address - Fax:770-838-9108
Practice Address - Street 1:157 CLINIC AVE STE 203
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-832-0429
Practice Address - Fax:770-838-9108
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT203196207R00000X
GA080127207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty