Healthcare Provider Details

I. General information

NPI: 1902038060
Provider Name (Legal Business Name): WALDO I ORTUZAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13869 KICKAPOO TR.
CARMEL IN
46033-8545
US

IV. Provider business mailing address

13869 KICKAPOO TR.
CARMEL IN
46033-8545
US

V. Phone/Fax

Practice location:
  • Phone: 317-433-0280
  • Fax: 317-277-3238
Mailing address:
  • Phone: 317-433-0280
  • Fax: 317-277-3238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01066109A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: