Healthcare Provider Details

I. General information

NPI: 1770625402
Provider Name (Legal Business Name): MR. PRAXEDES B ORTIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 4000
MARICAO PR
00606-9705
US

IV. Provider business mailing address

STREET INDIERA BAJA 426 ROAD KM 3.2 RR01 BUZON 4000
MARICAO PR
00606-9705
US

V. Phone/Fax

Practice location:
  • Phone: 787-838-3422
  • Fax:
Mailing address:
  • Phone: 787-838-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number004730
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: