Provider Demographics
NPI:1255348157
Name:ORTIZ, MYRNA (PT)
Entity type:Individual
Prefix:MS
First Name:MYRNA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 MT PROSPECT AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104
Mailing Address - Country:US
Mailing Address - Phone:973-485-4766
Mailing Address - Fax:
Practice Address - Street 1:465 MT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2907
Practice Address - Country:US
Practice Address - Phone:973-485-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA000334600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ552768Medicare ID - Type UnspecifiedPROVIDER ID