Provider Demographics
NPI:1851835946
Name:ORTIZ, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:ORTIZ
Suffix:
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 1:9 FARGO CT
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1506
Mailing Address - Country:US
Mailing Address - Phone:631-394-0931
Mailing Address - Fax:
Practice Address - Street 1:1162 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-3332
Practice Address - Country:US
Practice Address - Phone:631-394-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator