Healthcare Provider Details

I. General information

NPI: 1417010943
Provider Name (Legal Business Name): MAXIMINO RAFAEL ORTEGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE2 A15 PANORAMA ESTATE CALLE GEORGETTI 61 NARANJITO
BAYAMON PR
00957-4379
US

IV. Provider business mailing address

CALLE2A15 PANORAMA ESTATE
BAYAMON PR
00957-4379
US

V. Phone/Fax

Practice location:
  • Phone: 787-730-5309
  • Fax: 787-869-2575
Mailing address:
  • Phone: 787-730-5309
  • Fax: 787-869-2575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5564
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: