Provider Demographics
NPI:1669168779
Name:ORTEGA, SERGIO ENRIQUE (CHW)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:ENRIQUE
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:SERGIO
Other - Middle Name:E
Other - Last Name:ORTEGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CHW
Mailing Address - Street 1:1220 SW 25TH ST
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-1741
Mailing Address - Country:US
Mailing Address - Phone:503-701-1210
Mailing Address - Fax:503-988-5185
Practice Address - Street 1:600 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7317
Practice Address - Country:US
Practice Address - Phone:971-865-1188
Practice Address - Fax:503-988-5185
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108654172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker