Provider Demographics
NPI:1972635514
Name:ORTIZ, AGUSTIN A (M A)
Entity Type:Individual
Prefix:MR
First Name:AGUSTIN
Middle Name:A
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 QUAIL HILL DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1384
Mailing Address - Country:US
Mailing Address - Phone:760-510-9795
Mailing Address - Fax:
Practice Address - Street 1:120 W HAWTHORNE ST
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-2053
Practice Address - Country:US
Practice Address - Phone:760-731-3235
Practice Address - Fax:760-731-4950
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6528OtherMEDICAL STAFF NUMBER