Provider Demographics
NPI:1881045763
Name:ORTIZ, MARIA (AA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 TULLY RD STE A2
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2937
Mailing Address - Country:US
Mailing Address - Phone:209-622-5380
Mailing Address - Fax:
Practice Address - Street 1:1801 TULLY RD STE A2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-2937
Practice Address - Country:US
Practice Address - Phone:209-622-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24645174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist