Provider Demographics
NPI:1124279112
Name:ORTIZ RIVERA, EDGARDO
Entity type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:
Last Name:ORTIZ RIVERA
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:BO. SUSUA CALLE CEIBA # 113
Mailing Address - Street 2:
Mailing Address - City:SABANA GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00637-0000
Mailing Address - Country:US
Mailing Address - Phone:787-955-6784
Mailing Address - Fax:
Practice Address - Street 1:35 CALLE ANGEL G MARTINEZ
Practice Address - Street 2:
Practice Address - City:SABANA GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00637-1818
Practice Address - Country:US
Practice Address - Phone:787-955-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17340208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR17340Medicaid