Healthcare Provider Details

I. General information

NPI: 1659155653
Provider Name (Legal Business Name): JUSTIN LUIS ORTIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 ZANKER RD
SAN JOSE CA
95134-2107
US

IV. Provider business mailing address

2635 ZANKER RD
SAN JOSE CA
95134-2107
US

V. Phone/Fax

Practice location:
  • Phone: 408-757-8178
  • Fax:
Mailing address:
  • Phone: 408-757-8178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: