Provider Demographics
NPI:1609970094
Name:ORTIZ, PETRA J (MD)
Entity Type:Individual
Prefix:DR
First Name:PETRA
Middle Name:J
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12-C STREET
Mailing Address - Street 2:MIRADOR DE BORINQUEN GARDENS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6455
Mailing Address - Country:US
Mailing Address - Phone:787-720-3053
Mailing Address - Fax:787-287-4690
Practice Address - Street 1:102 CALLE CARAZO
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-5717
Practice Address - Country:US
Practice Address - Phone:787-720-3053
Practice Address - Fax:787-287-4690
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5349208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE00113Medicare UPIN
PR023369Medicare ID - Type Unspecified