Provider Demographics
NPI:1417010943
Name:ORTEGA, MAXIMINO RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MAXIMINO
Middle Name:RAFAEL
Last Name:ORTEGA
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:CALLE2A15 PANORAMA ESTATE
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957-4379
Mailing Address - Country:US
Mailing Address - Phone:787-730-5309
Mailing Address - Fax:787-869-2575
Practice Address - Street 1:CALLE2 A15 PANORAMA ESTATE
Practice Address - Street 2:CALLE GEORGETTI 61 NARANJITO
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00957-4379
Practice Address - Country:US
Practice Address - Phone:787-730-5309
Practice Address - Fax:787-869-2575
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5564OtherMEDICAL ESTATE LICENCE