Healthcare Provider Details

I. General information

NPI: 1750375184
Provider Name (Legal Business Name): JAMES PATRICK MORTIMER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAMES PATRICK MORTIMER DO

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL AVE
JEFFERSON NC
28640-9244
US

IV. Provider business mailing address

200 HOSPITAL AVE
JEFFERSON NC
28640-9244
US

V. Phone/Fax

Practice location:
  • Phone: 336-846-0805
  • Fax: 336-846-0746
Mailing address:
  • Phone: 336-846-0805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2023-01374
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1255054623
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: