Provider Demographics
NPI:1265424816
Name:CARDONA-ORTIZ, EMILIO (MD)
Entity type:Individual
Prefix:
First Name:EMILIO
Middle Name:
Last Name:CARDONA-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 1:27774 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2352
Mailing Address - Country:US
Mailing Address - Phone:248-356-5555
Mailing Address - Fax:248-356-5544
Practice Address - Street 1:10248 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1321
Practice Address - Country:US
Practice Address - Phone:313-841-7575
Practice Address - Fax:313-841-1713
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3477807-10Medicaid
C-79525Medicare UPIN
MI3477807-10Medicaid