MEDICARE: DR. JEAN NERVA DORTILUS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	P4438	TX
2	208D00000X	General Practice Physician	P4438	TX
3	2084P0800X	Psychiatry Physician	P4438	TX

General Provider Information

NPI Number	:	1063658524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEAN NERVA DORTILUS M.D.

Provider Business Mailing Address
First Line	:	3500 HILLCREST DR STE 7
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76708-3144
Country	:	US
Telephone Number	:	254-424-9523
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 HILLCREST DR STE 7
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76708-3144
Country	:	US
Telephone Number	:	254-424-9523
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2009
Last Update Date	:	05/27/2019

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