Provider Demographics
NPI:1871673392
Name:ORTEGA-JIMENEZ, VICTOR M (MD)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:M
Last Name:ORTEGA-JIMENEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:VICTOR
Other - Middle Name:M
Other - Last Name:ORTEGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 732901
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2901
Mailing Address - Country:US
Mailing Address - Phone:386-226-4590
Mailing Address - Fax:386-226-3371
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4152
Practice Address - Fax:386-254-4315
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33983207RC0200X
FLME0033983174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041490500Medicaid
FLD61999Medicare UPIN
FL17621Medicare ID - Type Unspecified