Provider Demographics
NPI:1639112956
Name:ORTIZ MATOS, LUIS JUAN
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:JUAN
Last Name:ORTIZ MATOS
Suffix:
Gender:M
Credentials:
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 209
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-0209
Mailing Address - Country:US
Mailing Address - Phone:787-859-0112
Mailing Address - Fax:787-859-6846
Practice Address - Street 1:CALLE 1 CASA 1URB. SANFELIZ
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-859-7182
Practice Address - Fax:787-859-6846
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9087208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF47565Medicare UPIN
PR0080671Medicare ID - Type Unspecified