Provider Demographics
NPI:1407699820
Name:ORTIZ, LUIS (OD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W RIVER SHORE WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13904 N DALE MABRY HWY STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2446
Practice Address - Country:US
Practice Address - Phone:813-908-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL6542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program