Provider Demographics
NPI:1720602352
Name:ORTIZ ROLDAN, OSVALDO SR
Entity Type:Individual
Prefix:
First Name:OSVALDO
Middle Name:
Last Name:ORTIZ ROLDAN
Suffix:SR
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 987
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754-0987
Mailing Address - Country:US
Mailing Address - Phone:787-559-5186
Mailing Address - Fax:
Practice Address - Street 1:BO FLORIDA CARR 183
Practice Address - Street 2:RAMAL 9929 KM 1.6
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754
Practice Address - Country:US
Practice Address - Phone:787-559-5186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR444409Medicaid