Provider Demographics
NPI:1376894923
Name:ORTANSA, PC
Entity type:Organization
Organization Name:ORTANSA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:PONDUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-218-6820
Mailing Address - Street 1:21001 N TATUM BLVD
Mailing Address - Street 2:STE 1630-463
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4206
Mailing Address - Country:US
Mailing Address - Phone:312-218-6820
Mailing Address - Fax:
Practice Address - Street 1:1800 E VAN BUREN ST.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3742
Practice Address - Country:US
Practice Address - Phone:602-251-8316
Practice Address - Fax:480-333-5165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-23
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42568207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ743215Medicaid
AZ743215Medicaid