Provider Demographics
NPI:1427599695
Name:ORTIZ, ANGEL LUIS
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:LUIS
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANGEL
Other - Middle Name:LUIS
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:AA9 CALLE FRESNO
Mailing Address - Street 2:GLENVIEW GARDENS
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730-1610
Mailing Address - Country:US
Mailing Address - Phone:787-216-3621
Mailing Address - Fax:
Practice Address - Street 1:AA9 CALLE FRESNO
Practice Address - Street 2:GLENVIEW GARDENS
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730-1610
Practice Address - Country:US
Practice Address - Phone:787-216-3621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR022514208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program