Healthcare Provider Details

I. General information

NPI: 1215294749
Provider Name (Legal Business Name): JACOB ROBERTO ORTIZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2012
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 HUGER DR
GEORGETOWN SC
29440-3322
US

IV. Provider business mailing address

PO BOX 421718
GEORGETOWN SC
29442-4203
US

V. Phone/Fax

Practice location:
  • Phone: 843-235-3131
  • Fax: 843-237-9797
Mailing address:
  • Phone: 843-527-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2024-00383
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2024-00383
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101280647
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: