Provider Demographics
NPI:1538281597
Name:ORTEGA, ANTONIO JUAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:JUAN
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 PALMETTO ST
Mailing Address - Street 2:#3R
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2750
Mailing Address - Country:US
Mailing Address - Phone:347-689-9914
Mailing Address - Fax:
Practice Address - Street 1:26 COURT ST
Practice Address - Street 2:SUITE 1711
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11242-0103
Practice Address - Country:US
Practice Address - Phone:718-237-2127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018373103T00000X
FLPY8293103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical