Provider Demographics
NPI:1114758901
Name:ORTIZ, EDWIN
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:ORTIZ
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 1:5034 GRAND TETON CT
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-0010
Mailing Address - Country:US
Mailing Address - Phone:407-353-4786
Mailing Address - Fax:
Practice Address - Street 1:999 S VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-6564
Practice Address - Country:US
Practice Address - Phone:386-917-7681
Practice Address - Fax:386-774-2561
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11033832363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily