=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154377398
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHZAIDA ORTIZ-CRUZ MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 ZONA IND REPARADA 2
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00716-2348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-840-0052
-----------------------------------------------------
Fax | 787-848-1306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 1 BOX 14938
-----------------------------------------------------
City | COAMO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00769-9744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-840-0052
-----------------------------------------------------
Fax | 787-848-1306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 14259
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------