MEDICARE: YANCARLOS ORTEGA GONZALEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	O632960870580	OTHER	FL	DRIVER LICENCE

General Provider Information

NPI Number	:	1063918274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YANCARLOS ORTEGA GONZALEZ

Provider Business Mailing Address
First Line	:	6914 W 24TH LN
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-5471
Country	:	US
Telephone Number	:	786-351-0408
Fax Number	:

Provider Business Practice Location Address
First Line	:	6914 W 24TH LN
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-5471
Country	:	US
Telephone Number	:	786-351-0408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2018
Last Update Date	:	04/05/2018

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