Basic Information
| Provider Information | |||||||||
| NPI: | 1124059225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICARDO-ORTIZ | ||||||||
| FirstName: | MARYLIN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 TEJAS PL | ||||||||
| Address2: | PO BOX 430 | ||||||||
| City: | NIPOMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934449123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059293211 | ||||||||
| FaxNumber: | 8059296440 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | PASO ROBLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934463168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052387250 | ||||||||
| FaxNumber: | 8059296440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A29659 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1124045042 | 01 | CA | LOS ROBLES NPI # | OTHER | FHC70737F | 05 | CA | MEDICAID | W1508 | 01 | CA | MEDICARE GROUP PLAN | OTHER |