Healthcare Provider Details

I. General information

NPI: 1083810162
Provider Name (Legal Business Name): DR. LUIS ANTONIO ORTIZ HEREDIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARIBBEAN MEDICAL CENTER PONCE BY PASS 2275 SUITE 202
PONCE PR
00717-0020
US

IV. Provider business mailing address

PO BOX 335251
PONCE PR
00733-5251
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-1455
  • Fax: 787-848-4657
Mailing address:
  • Phone: 787-362-0722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number16621
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: