Provider Demographics
NPI:1720021702
Name:ORTEGO, TERRYL JEAN (MD)
Entity Type:Individual
Prefix:MR
First Name:TERRYL
Middle Name:JEAN
Last Name:ORTEGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-9682
Mailing Address - Country:US
Mailing Address - Phone:479-770-8090
Mailing Address - Fax:479-770-8062
Practice Address - Street 1:116 W MONROE AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9682
Practice Address - Country:US
Practice Address - Phone:479-770-8090
Practice Address - Fax:479-770-8062
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-3334207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105379001Medicaid
AR105379001Medicaid
ARB90456Medicare UPIN