Provider Demographics
NPI:1720184401
Name:ORTIZ, IVAN A (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:A
Last Name:ORTIZ
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:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:1500 CITYWEST BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2300
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6553207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158819610Medicaid
TX8FX657OtherBCBS
TX158819602Medicaid
TX158819609Medicaid
TXP01740797OtherRR
TX8R1201OtherBCBS
TX158819609Medicaid
TX349048YK6UMedicare PIN
TX8FX657OtherBCBS
H86809Medicare UPIN