Provider Demographics
NPI:1508993791
Name:JORGE A. ONTIVEROS, M.D., P.A.
Entity Type:Organization
Organization Name:JORGE A. ONTIVEROS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:ONTIVEROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-533-8545
Mailing Address - Street 1:PO BOX 2024
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-2024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10705 PLANO RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-5343
Practice Address - Country:US
Practice Address - Phone:214-553-8545
Practice Address - Fax:214-553-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDH1290OtherRR MEDICARE
TX0097QVOtherBCBS
TX176862401Medicaid
TXH04561Medicare UPIN
TX0097QVOtherBCBS