Provider Demographics
NPI:1710038690
Name:ORTIZ, TIMOTHY P (O D)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1209
Mailing Address - Country:US
Mailing Address - Phone:815-942-5500
Mailing Address - Fax:815-942-1851
Practice Address - Street 1:880 BEDFORD RD
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1209
Practice Address - Country:US
Practice Address - Phone:815-942-5500
Practice Address - Fax:815-942-1851
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046 008365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008365Medicaid
0003084001OtherBLUE CROSS BLUE SHIELD IL
IL922400Medicare ID - Type Unspecified
IL046008365Medicaid