Healthcare Provider Details

I. General information

NPI: 1235645094
Provider Name (Legal Business Name): JOSE EMILIO ORTIZ BETANCOURT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HF16 CALLE LIZZIE GRAHAM
TOA BAJA PR
00949-3634
US

IV. Provider business mailing address

655 PASEO GRAN VISTA CARR 931 APT B309
GURABO PR
00778
US

V. Phone/Fax

Practice location:
  • Phone: 787-795-2935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23420
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: