Provider Demographics
NPI:1578699443
Name:ORTIZ, CARLOS WILFREDO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:WILFREDO
Last Name:ORTIZ
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 1:100 NW 170TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5510
Mailing Address - Country:US
Mailing Address - Phone:305-685-5688
Mailing Address - Fax:
Practice Address - Street 1:100 NW 170TH ST STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-5510
Practice Address - Country:US
Practice Address - Phone:305-685-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR08340208000000X
FLACN412208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR29734Medicare PIN