Provider Demographics
NPI:1699833376
Name:DORTA, LUIS M (MD)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:M
Last Name:DORTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4633 ISLA VERDE AVE
Mailing Address - Street 2:PMB 1213
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00979
Mailing Address - Country:US
Mailing Address - Phone:787-281-0032
Mailing Address - Fax:787-767-3412
Practice Address - Street 1:CALLE MAYAGUEZ #45
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917
Practice Address - Country:US
Practice Address - Phone:787-281-0032
Practice Address - Fax:787-767-3412
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR76562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR81531Medicare ID - Type Unspecified