Healthcare Provider Details

I. General information

NPI: 1033109210
Provider Name (Legal Business Name): KEVIN L MORTARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 COMMANCHE AVE
GREEN BAY WI
54313-5751
US

IV. Provider business mailing address

1580 COMMANCHE AVE
GREEN BAY WI
54313-5751
US

V. Phone/Fax

Practice location:
  • Phone: 920-435-8326
  • Fax: 920-430-4659
Mailing address:
  • Phone: 920-435-8326
  • Fax: 920-430-4659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number48997-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: