Healthcare Provider Details

I. General information

NPI: 1629502463
Provider Name (Legal Business Name): PEDRO ORTIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 DELTONA BLVD APT 40A
DELTONA FL
32725-6386
US

IV. Provider business mailing address

1205 S WOODLAND BLVD STE 3
DELAND FL
32720-7464
US

V. Phone/Fax

Practice location:
  • Phone: 386-202-6025
  • Fax:
Mailing address:
  • Phone: 386-202-6025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number008557
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9119021
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: