Healthcare Provider Details

I. General information

NPI: 1740106798
Provider Name (Legal Business Name): ANGELO ORTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 CECIL DR
CHESTER MD
21619-2139
US

IV. Provider business mailing address

2715 CECIL DR
CHESTER MD
21619-2139
US

V. Phone/Fax

Practice location:
  • Phone: 410-330-8473
  • Fax:
Mailing address:
  • Phone: 410-330-8457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number10276642266
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: