Provider Demographics
NPI:1124316856
Name:ORTIZ, ILEANA IVONNE (MD)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:IVONNE
Last Name: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 1:5410 MARYLAND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5339
Mailing Address - Country:US
Mailing Address - Phone:615-371-4423
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMSTEAD TURNPIKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554
Practice Address - Country:US
Practice Address - Phone:516-572-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ49413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY390200000XOtherSTUDENT, HEALTH CARE