Provider Demographics
NPI:1730507070
Name:ORTIZ, IVY G (BA)
Entity type:Individual
Prefix:MS
First Name:IVY
Middle Name:G
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W GRIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1234
Mailing Address - Country:US
Mailing Address - Phone:575-647-2800
Mailing Address - Fax:575-647-2898
Practice Address - Street 1:315 S HUDSON ST
Practice Address - Street 2:STE 6
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-6184
Practice Address - Country:US
Practice Address - Phone:575-388-4412
Practice Address - Fax:575-537-1170
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid