Healthcare Provider Details

I. General information

NPI: 1083173348
Provider Name (Legal Business Name): RYAN BRADLEY ESTACIO ORTIZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E COOLEY DR
COLTON CA
92324-3905
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-4100
  • Fax:
Mailing address:
  • Phone: 951-982-9900
  • Fax: 951-682-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA180446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: