Provider Demographics
NPI:1811692452
Name:ORTIZ, BENJAMIN (PA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 SAN RAFAEL STREET , BO SALUD.
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680
Mailing Address - Country:US
Mailing Address - Phone:787-464-5040
Mailing Address - Fax:
Practice Address - Street 1:229 SAN RAFAEL STREET , BO SALUD.
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-464-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR01184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant