Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0210X | Pediatric Nephrologist | 051260 | GA |
NPI | 1114026242 |
---|---|
Provider Name | Luis A. Ortiz |
First Address | Augusta, GA 30901-2650 |
Second Address | Augusta, GA 30912-0004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 30/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000947757A | (05) | GA |
G51260 | (05) | SC |
H58434 | (02) |