Provider Demographics
NPI:1225162852
Name:ORTIZ, ELIZA (PT)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2014 WILLIAMSBRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:718-239-4314
Mailing Address - Fax:718-239-4315
Practice Address - Street 1:2014 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1603
Practice Address - Country:US
Practice Address - Phone:718-239-4314
Practice Address - Fax:718-239-4315
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2008-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02234797Medicaid
NY02234797Medicaid