Provider Demographics
NPI:1295784007
Name:ONTIVEROS, JORGE ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ANTONIO
Last Name:ONTIVEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 678040
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8040
Mailing Address - Country:US
Mailing Address - Phone:214-320-7770
Mailing Address - Fax:833-535-1069
Practice Address - Street 1:820 E CARTWRIGHT RD STE 100
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-6063
Practice Address - Country:US
Practice Address - Phone:214-320-7600
Practice Address - Fax:833-535-1069
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7852207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F1299Medicare ID - Type Unspecified
TXHO 4561Medicare UPIN