Provider Demographics
NPI:1255746152
Name:MENDEZ ORTIZ, JORGE WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:WILSON
Last Name:MENDEZ ORTIZ
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 1:677 CALLE AGUAS CALIENTES
Mailing Address - Street 2:URB. VENUS GARDENS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-4618
Mailing Address - Country:US
Mailing Address - Phone:787-397-4516
Mailing Address - Fax:
Practice Address - Street 1:CARR #2 KM 47.0
Practice Address - Street 2:CAMPO ALEGRE
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-854-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18800208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice