Healthcare Provider Details

I. General information

NPI: 1184748261
Provider Name (Legal Business Name): RICHARD H. MORTARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 REGENCY ROAD BLDG. 100
LEXINGTON KY
40503
US

IV. Provider business mailing address

280 PASADENA DRIVE
LEXINGTON KY
40503
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-1316
  • Fax:
Mailing address:
  • Phone: 859-278-1316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number14904
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: