Provider Demographics
NPI:1508598178
Name:DAVID ORTEGA, JOEL
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:DAVID ORTEGA
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 1:1101 MIRANDA LN STE 131
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-0771
Mailing Address - Country:US
Mailing Address - Phone:407-565-9477
Mailing Address - Fax:407-915-3567
Practice Address - Street 1:1101 MIRANDA LN STE 131
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0771
Practice Address - Country:US
Practice Address - Phone:407-565-9477
Practice Address - Fax:407-915-3567
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11020510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health