Provider Demographics
NPI:1417059775
Name:ORTIZ, MARIA R (DPM)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:R
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 CHICAGO AVENUE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-475-5831
Mailing Address - Fax:847-475-5831
Practice Address - Street 1:1507 CHICAGO AVENUE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-475-5831
Practice Address - Fax:847-475-5831
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01605578OtherBLUECROSSBLUESHEILD-IL
U38612Medicare UPIN
319440Medicare ID - Type Unspecified