Provider Demographics
NPI:1376602508
Name:ORTIZ COLON, JUAN M SR (OD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:ORTIZ COLON
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 CARR 891 ST 19
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783
Mailing Address - Country:US
Mailing Address - Phone:787-859-7958
Mailing Address - Fax:787-859-7958
Practice Address - Street 1:950 CARR 891 STE 19
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-859-7958
Practice Address - Fax:787-859-7958
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR660806855Medicaid
PR58009OtherSSS
660444808OtherMCS