Provider Demographics
NPI:1265762397
Name:ORTIZ, JORGE EDUARDO (PT)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:EDUARDO
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7469 ENCHANTED STREAM DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4964
Mailing Address - Country:US
Mailing Address - Phone:936-443-4745
Mailing Address - Fax:936-539-6421
Practice Address - Street 1:7469 ENCHANTED STREAM DR
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-4964
Practice Address - Country:US
Practice Address - Phone:936-443-7545
Practice Address - Fax:936-539-6421
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1081743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist