Provider Demographics
NPI:1861748709
Name:ORTIZ, RAFAEL NATHAN (BSW)
Entity type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:NATHAN
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:MR
Other - First Name:RAFAEL
Other - Middle Name:NATHAN
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSW
Mailing Address - Street 1:315 N. LAKEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792
Mailing Address - Country:US
Mailing Address - Phone:305-491-8693
Mailing Address - Fax:
Practice Address - Street 1:315 N LAKEMONT AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3205
Practice Address - Country:US
Practice Address - Phone:407-792-5534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9999999999Medicaid