Provider Demographics
NPI:1598884587
Name:ORTIZ, SALVADOR III (APA-C)
Entity Type:Individual
Prefix:MR
First Name:SALVADOR
Middle Name:
Last Name:ORTIZ
Suffix:III
Gender:M
Credentials:APA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5007
Mailing Address - Country:US
Mailing Address - Phone:573-774-0477
Mailing Address - Fax:
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-0039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05173363A00000X
MO2016037997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant