Provider Demographics
NPI:1518945062
Name:ORTEGA, TEODORO K (MD)
Entity Type:Individual
Prefix:DR
First Name:TEODORO
Middle Name:K
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 1:5080 BAYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2522
Mailing Address - Country:US
Mailing Address - Phone:850-477-4074
Mailing Address - Fax:850-476-9234
Practice Address - Street 1:5080 BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2522
Practice Address - Country:US
Practice Address - Phone:850-477-4074
Practice Address - Fax:850-476-9234
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME22905208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17313OtherBC/BS OF FL ID NUMBER
FL590-02294OtherBC/BS OF AL ID NUMBER
FLME 22905OtherSTATE LICENSE NUMBER
FL17313ZMedicare PIN
FLME 22905OtherSTATE LICENSE NUMBER