Provider Demographics
NPI:1750312450
Name:ORTIZ, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
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 1:465 MT. PROSPECT AVE.
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104
Mailing Address - Country:US
Mailing Address - Phone:973-483-3640
Mailing Address - Fax:973-483-0132
Practice Address - Street 1:465 MT. PROSPECT AVE.
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104
Practice Address - Country:US
Practice Address - Phone:973-483-3640
Practice Address - Fax:973-483-0132
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 40692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ033691BXBOtherMEDICARE GROUP SUFFIX
NJ1259202Medicaid
NJ527732OtherMEDICARE GROUP
NJ527732OtherMEDICARE GROUP
NJ033691Medicare PIN