Provider Demographics
NPI:1245827351
Name:ORTIZ, IAN ALEXANDER
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:ALEXANDER
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 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:484-214-6604
Mailing Address - Fax:267-479-1321
Practice Address - Street 1:9975 TAVISTOCK LAKES BLVD STE 220
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7665
Practice Address - Country:US
Practice Address - Phone:844-407-4070
Practice Address - Fax:321-248-4035
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
FL9114096363A00000X
TXPA14600363A00000X
FLPA9114096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program