Healthcare Provider Details

I. General information

NPI: 1053458125
Provider Name (Legal Business Name): RUBEN ORTIZ LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8304 SHAVER DR
EL PASO TX
79925-4907
US

IV. Provider business mailing address

3905 MELCER DR STE 601
ROWLETT TX
75088-4033
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberSA00086
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00086
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: