Provider Demographics
NPI:1477095016
Name:ORTIZ MARTINEZ, REYNALDO J
Entity type:Individual
Prefix:
First Name:REYNALDO
Middle Name:J
Last Name:ORTIZ MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15800 PINES BLVD STE 349
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1212
Mailing Address - Country:US
Mailing Address - Phone:954-362-5215
Mailing Address - Fax:954-362-5210
Practice Address - Street 1:9130 NW 162ND TER
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33018-6302
Practice Address - Country:US
Practice Address - Phone:786-720-6082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-21-48841103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019542300Medicaid