Healthcare Provider Details

I. General information

NPI: 1285014845
Provider Name (Legal Business Name): ANDY ORTA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7482 CENTER ST UNIT 100
MENTOR OH
44060
US

IV. Provider business mailing address

7482 CENTER ST UNIT 100
MENTOR OH
44060-5847
US

V. Phone/Fax

Practice location:
  • Phone: 440-357-8418
  • Fax: 440-255-9400
Mailing address:
  • Phone: 440-357-8418
  • Fax: 440-255-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003885
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: