Provider Demographics
NPI:1972057958
Name:ORTEGA, PETRA DENISS
Entity type:Individual
Prefix:MS
First Name:PETRA
Middle Name:DENISS
Last Name:ORTEGA
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 1:430 F ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3711
Mailing Address - Country:US
Mailing Address - Phone:619-420-3620
Mailing Address - Fax:619-420-8722
Practice Address - Street 1:430 F ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3711
Practice Address - Country:US
Practice Address - Phone:619-420-3620
Practice Address - Fax:619-420-8722
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37LAMedicaid