Healthcare Provider Details

I. General information

NPI: 1578657458
Provider Name (Legal Business Name): EVAN E MORTIMER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W PRESTON ST RM 309
BALTIMORE MD
21201-2301
US

IV. Provider business mailing address

10222 WESTWOOD DR
COLUMBIA MD
21044-3906
US

V. Phone/Fax

Practice location:
  • Phone: 410-767-6718
  • Fax: 410-333-5233
Mailing address:
  • Phone: 410-997-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0032020
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: