Provider Demographics
NPI:1487490215
Name:SANTIAGO ORTIZ, DEMIAN JESUS
Entity type:Individual
Prefix:
First Name:DEMIAN
Middle Name:JESUS
Last Name:SANTIAGO ORTIZ
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 1:1731 SW 66TH DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-5369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7081 GRAND NATIONAL DR STE AND114
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8385
Practice Address - Country:US
Practice Address - Phone:561-809-5074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician