=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316966468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIMARY ORTIZ MENDEZ I MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 11/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 AVE. HOSTOS , STE. 311, COND. MEDICAL CENTER PLAZA
-----------------------------------------------------
City | MAYAGUEZ
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00682-1541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-249-5062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 CARR 307 APARTADO 108 EDIFICIOS OLAS A8, CABOQUERON RESORT
-----------------------------------------------------
City | BOQUERON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00622-9768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-249-5062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ACN558
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 14094
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------