Healthcare Provider Details

I. General information

NPI: 1740713643
Provider Name (Legal Business Name): GONZALO ORTIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 09/07/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 DUNLAWTON AVE
PORT ORANGE FL
32127-9226
US

IV. Provider business mailing address

3824 OAKWATER CIR
ORLANDO FL
32806-6263
US

V. Phone/Fax

Practice location:
  • Phone: 800-255-7188
  • Fax: 407-423-9040
Mailing address:
  • Phone: 407-893-8200
  • Fax: 407-893-8210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME148138
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberME148138
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: