Provider Demographics
NPI:1629044128
Name:DORTA, HUMBERTO RAMON (MD)
Entity Type:Individual
Prefix:
First Name:HUMBERTO
Middle Name:RAMON
Last Name:DORTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-333-5061
Mailing Address - Fax:814-333-5067
Practice Address - Street 1:18201 CONNEAUT LAKE RD
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335
Practice Address - Country:US
Practice Address - Phone:814-333-5061
Practice Address - Fax:814-333-5067
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4273482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI24688Medicare UPIN