Provider Demographics
NPI:1063918274
Name:ORTEGA GONZALEZ, YANCARLOS
Entity type:Individual
Prefix:
First Name:YANCARLOS
Middle Name:
Last Name:ORTEGA GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6914 W 24TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5471
Mailing Address - Country:US
Mailing Address - Phone:786-351-0408
Mailing Address - Fax:
Practice Address - Street 1:6914 W 24TH LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5471
Practice Address - Country:US
Practice Address - Phone:786-351-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO632960870580OtherDRIVER LICENCE