Provider Demographics
NPI:1952508186
Name:ORTEGA, ERIK LILLEGRAVEN (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:LILLEGRAVEN
Last Name:ORTEGA
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:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:
Practice Address - Street 1:240 W THOMAS RD STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4407
Practice Address - Country:US
Practice Address - Phone:602-406-6262
Practice Address - Fax:602-406-6260
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ420392084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ448447Medicaid
AZZ131672Medicare PIN