Healthcare Provider Details

I. General information

NPI: 1720648025
Provider Name (Legal Business Name): AMANDA YADIRAH ORTIZ VICIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 09/23/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

C16 CALLE AZUCENA URB GREEN HILLS
GUAYAMA PR
00784
US

IV. Provider business mailing address

CALLE CESAR GONZALEZ CONDOMINIO PARQUE DE LAS FUENTES APT 2303
SAN JUAN PR
00918
US

V. Phone/Fax

Practice location:
  • Phone: 787-214-3740
  • Fax:
Mailing address:
  • Phone: 787-214-3740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number023723
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: