Provider Demographics
NPI:1699839779
Name:ORTIZ, DIANA C
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:C
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 N MICHIGAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1244
Mailing Address - Country:US
Mailing Address - Phone:574-647-1842
Mailing Address - Fax:574-647-1825
Practice Address - Street 1:325 N LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1208
Practice Address - Country:US
Practice Address - Phone:574-647-2171
Practice Address - Fax:574-647-1351
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2006747000Medicaid