Healthcare Provider Details

I. General information

NPI: 1730515479
Provider Name (Legal Business Name): MRS. EDITH ELIZABETH ORTIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LOUIS AVE
SOUTH FLORAL PARK NY
11001-3525
US

IV. Provider business mailing address

300 LOUIS AVE
SOUTH FLORAL PARK NY
11001-3525
US

V. Phone/Fax

Practice location:
  • Phone: 646-209-9568
  • Fax:
Mailing address:
  • Phone: 646-209-9568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number359276
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: