Provider Demographics
NPI:1609863463
Name:ORTIZ, JUAN JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:207 SPARKS AVE STE 100
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3739
Practice Address - Country:US
Practice Address - Phone:812-284-5411
Practice Address - Fax:812-284-0144
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054884A207R00000X, 207RC0000X
KY28206207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY28206OtherSTATE LICENSE
IN01054884AOtherSTATE LICENSE
KY64282064Medicaid
IN200281160Medicaid