Provider Demographics
NPI:1437861200
Name:ORTIZ, ALONZO
Entity Type:Individual
Prefix:
First Name:ALONZO
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-4232
Mailing Address - Country:US
Mailing Address - Phone:608-278-8037
Mailing Address - Fax:
Practice Address - Street 1:5702 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-4232
Practice Address - Country:US
Practice Address - Phone:608-278-8037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.305298183500000X
WI21512-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist