Provider Demographics
NPI:1699790287
Name:ORTEZA, DEOFIL LUZOD (MD)
Entity type:Individual
Prefix:
First Name:DEOFIL
Middle Name:LUZOD
Last Name:ORTEZA
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 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356
Mailing Address - Country:US
Mailing Address - Phone:815-875-2811
Mailing Address - Fax:
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-875-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054242207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00600116OtherBLUE CROSS BLUE SHIELD
1023186517OtherORGANIZATION IDENTIFIER
IL036054242Medicaid
ILL06500OtherMEDCARE LEGACY #
IL00600116OtherBLUE CROSS BLUE SHIELD
1699790287Medicare ID - Type UnspecifiedNPI