Provider Demographics
NPI:1598748527
Name:ORTA, IVAN JOHN (DPT)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:JOHN
Last Name:ORTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2107
Mailing Address - Country:US
Mailing Address - Phone:336-258-8252
Mailing Address - Fax:336-258-8253
Practice Address - Street 1:2015 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621
Practice Address - Country:US
Practice Address - Phone:336-258-8252
Practice Address - Fax:336-258-8253
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7718203OtherAETNA
NC128K3OtherBCBS
NC128K3OtherBCBS