Provider Demographics
NPI:1124059225
Name:RICARDO-ORTIZ, MARYLIN B (MD)
Entity type:Individual
Prefix:
First Name:MARYLIN
Middle Name:B
Last Name:RICARDO-ORTIZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:805-929-6440
Practice Address - Street 1:345 SPRING ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-3168
Practice Address - Country:US
Practice Address - Phone:805-238-7250
Practice Address - Fax:805-929-6440
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29659208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124045042OtherLOS ROBLES NPI #
CAFHC70737FMedicaid
CAW1508OtherMEDICARE GROUP PLAN
CAWA29659AMedicare PIN
CAFHC70737FMedicaid