Healthcare Provider Details

I. General information

NPI: 1023200813
Provider Name (Legal Business Name): DALE B MORTIMER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 NE 7TH AVE SUITE 385
VANCOUVER WA
98685-2955
US

IV. Provider business mailing address

800 NE TENNEY ROAD PMB 110 232
VANCOUVER WA
98685-2831
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-9058
  • Fax: 360-567-0861
Mailing address:
  • Phone: 360-882-9058
  • Fax: 360-567-0861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00028371
License Number StateWA

VIII. Authorized Official

Name: DALE BURTON MORTIMER
Title or Position: CHAIRMAN AND PRESIDENT
Credential: MD
Phone: 360-882-9058