Provider Demographics
NPI:1063155471
Name:ORTIZ, JOSUE DAVID (DC)
Entity type:Individual
Prefix:
First Name:JOSUE
Middle Name:DAVID
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W RANDOLPH ST APT 707
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-3514
Mailing Address - Country:US
Mailing Address - Phone:864-412-9459
Mailing Address - Fax:
Practice Address - Street 1:2018 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616
Practice Address - Country:US
Practice Address - Phone:312-753-3249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013858111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor