MEDICARE: MR. DAVID CONRAD ORTMEIER LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	AT0820	TX

General Provider Information

NPI Number	:	1154922755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID CONRAD ORTMEIER LAT

Provider Business Mailing Address
First Line	:	1427 MONARCH TRL
Second Line	:
City	:	NORTHLAKE
State	:	TX
Zip	:	76226-2729
Country	:	US
Telephone Number	:	214-449-8759
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 WICHITA TRL
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-5628
Country	:	US
Telephone Number	:	682-237-0232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	11/02/2020

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Directions to “ MR. DAVID CONRAD ORTMEIER LAT” Practice Location

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