Provider Demographics
NPI:1386276392
Name:ORTIZ RIVERA, MIGUEL ANGEL (MD)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:ORTIZ RIVERA
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:P. O. BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-4401
Mailing Address - Fax:217-545-1793
Practice Address - Street 1:701 N 1ST
Practice Address - Street 2:SUITE D308
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-545-4401
Practice Address - Fax:217-545-1793
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125080748208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program