Provider Demographics
NPI:1720648025
Name:ORTIZ VICIL, AMANDA YADIRAH
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:YADIRAH
Last Name:ORTIZ VICIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE CESAR GONZALEZ CONDOMINIO PARQUE DE LAS FUENTES
Mailing Address - Street 2:APT 2303
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-214-3740
Mailing Address - Fax:
Practice Address - Street 1:C16 CALLE AZUCENA
Practice Address - Street 2:URB GREEN HILLS
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-214-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR023723207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6164903OtherLICENCE NUMBER