Healthcare Provider Details

I. General information

NPI: 1225100308
Provider Name (Legal Business Name): JUAN ANTONIO ORTIZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUAN ANTONIO ORTIZ PEREZ M.D. FACS

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9104 FALLS OF NEUSE RD STE 204
RALEIGH NC
27615-2493
US

IV. Provider business mailing address

9104 FALLS OF NEUSE RD STE 204
RALEIGH NC
27615-2493
US

V. Phone/Fax

Practice location:
  • Phone: 919-706-4900
  • Fax: 919-706-4901
Mailing address:
  • Phone: 919-706-4909
  • Fax: 919-706-4901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2011-00555
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: