Provider Demographics
NPI:1447293816
Name:ORTIZ MATOS, JUAN LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:LUIS
Last Name:ORTIZ MATOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-1117
Mailing Address - Country:US
Mailing Address - Phone:787-406-0626
Mailing Address - Fax:787-859-6846
Practice Address - Street 1:CALLE 1 CASA 1 URB. SANFELIZ
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-859-0112
Practice Address - Fax:787-859-6846
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF25930Medicare UPIN
PR0081924Medicare ID - Type Unspecified