Provider Demographics
NPI:1588651939
Name:ORTIZ, GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
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 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:1200 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4437
Practice Address - Country:US
Practice Address - Phone:618-993-5686
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160757207W00000X
IL036-078064207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078064Medicaid
MO133925OtherANTHEM BLUE CROSS BLUE SHIELD
101069OtherHEALTHLINK
IL180006269OtherMEDICARE RAILROAD
034235OtherHEALTH ALLIANCE
MO203419007Medicaid
237696OtherHARMONY HEALTH PLAN
IL180006269OtherMEDICARE RAILROAD
MO133925OtherANTHEM BLUE CROSS BLUE SHIELD
ILP12421Medicare PIN