Provider Demographics
NPI:1629004015
Name:HORTILLOSA, MARIA A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:A
Last Name:HORTILLOSA
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 1:3513 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965
Mailing Address - Country:US
Mailing Address - Phone:606-248-5187
Mailing Address - Fax:606-248-5823
Practice Address - Street 1:3513 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-248-5187
Practice Address - Fax:606-248-5823
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20321207L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64203219Medicaid
VA005630291Medicaid
TN21300Medicaid
KY1300601Medicare ID - Type Unspecified
TN21300Medicaid