Healthcare Provider Details

I. General information

NPI: 1467604025
Provider Name (Legal Business Name): DALE BURTON MORTIMER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
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

10000 NE 7TH AVE SUITE #385
VANCOUVER WA
98685-2955
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:
Title or Position:
Credential:
Phone: