Provider Demographics
NPI:1104967520
Name:ORTEGA, EDDY O (MD)
Entity type:Individual
Prefix:
First Name:EDDY
Middle Name:O
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 47TH ST
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08110-4138
Mailing Address - Country:US
Mailing Address - Phone:609-561-1700
Mailing Address - Fax:
Practice Address - Street 1:301 SPRING GARDEN RD
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-2516
Practice Address - Country:US
Practice Address - Phone:609-651-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05943600283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD06293600OtherCDS
NJD06293600OtherCDS