Provider Demographics
NPI:1760195796
Name:LUIS CARLOS O ORTEGA
Entity Type:Organization
Organization Name:LUIS CARLOS O ORTEGA
Other - Org Name:LUIS CARLOS O ORTEGA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:LUISA
Authorized Official - Middle Name:CARLA
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-629-0131
Mailing Address - Street 1:620 S TONOPAH DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4029
Mailing Address - Country:US
Mailing Address - Phone:702-413-1391
Mailing Address - Fax:702-413-1392
Practice Address - Street 1:620 S TONOPAH DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4029
Practice Address - Country:US
Practice Address - Phone:702-413-1391
Practice Address - Fax:702-413-1392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-04
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019513Medicaid