Healthcare Provider Details

I. General information

NPI: 1114585957
Provider Name (Legal Business Name): NICOLE ORTIZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5395 RUFFIN RD STE 204
SAN DIEGO CA
92123-1338
US

IV. Provider business mailing address

5395 RUFFIN RD STE 204
SAN DIEGO CA
92123-1338
US

V. Phone/Fax

Practice location:
  • Phone: 858-571-3630
  • Fax: 858-295-3948
Mailing address:
  • Phone: 858-571-3630
  • Fax: 858-295-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number197390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: