Healthcare Provider Details

I. General information

NPI: 1295784007
Provider Name (Legal Business Name): JORGE ANTONIO ONTIVEROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13709 S SANTA FE AVE STE B
OKLAHOMA CITY OK
73170-7327
US

IV. Provider business mailing address

13709 S SANTA FE AVE STE B
OKLAHOMA CITY OK
73170-7327
US

V. Phone/Fax

Practice location:
  • Phone: 405-794-4484
  • Fax: 888-440-5383
Mailing address:
  • Phone: 405-794-4474
  • Fax: 888-440-5383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK7852
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: