Healthcare Provider Details

I. General information

NPI: 1154922755
Provider Name (Legal Business Name): DAVID CONRAD ORTMEIER LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 WICHITA TRL
FLOWER MOUND TX
75022-5628
US

IV. Provider business mailing address

1427 MONARCH TRL
NORTHLAKE TX
76226-2729
US

V. Phone/Fax

Practice location:
  • Phone: 682-237-0232
  • Fax:
Mailing address:
  • Phone: 214-449-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberAT0820
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: