Healthcare Provider Details

I. General information

NPI: 1124745351
Provider Name (Legal Business Name): LUIS ORTEGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 10/27/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 WEST 8TH STREET DIVISION OF CARDIOLOGY-ACC BUILDING 5TH FLOOR
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

7800 POINT MEADOWS DR APT 422
JACKSONVILLE FL
32256-4613
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-2655
  • Fax:
Mailing address:
  • Phone: 904-316-0981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMFC1866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: