Healthcare Provider Details

I. General information

NPI: 1053301499
Provider Name (Legal Business Name): ILEANA ORTIZ-EVANS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 US ROUTE 22
PHILLIPSBURG NJ
08865
US

IV. Provider business mailing address

PO BOX 758952
BALTIMORE MD
21275-8952
US

V. Phone/Fax

Practice location:
  • Phone: 908-213-2211
  • Fax: 908-213-9913
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD071288L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA68294
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: