Provider Demographics
NPI:1023200813
Name:DALE B MORTIMER MD PC
Entity type:Organization
Organization Name:DALE B MORTIMER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:MORTIMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-882-9058
Mailing Address - Street 1:800 NE TENNEY ROAD
Mailing Address - Street 2:PMB 110 232
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2831
Mailing Address - Country:US
Mailing Address - Phone:360-882-9058
Mailing Address - Fax:360-567-0861
Practice Address - Street 1:10000 NE 7TH AVE
Practice Address - Street 2:SUITE 385
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2955
Practice Address - Country:US
Practice Address - Phone:360-882-9058
Practice Address - Fax:360-567-0861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000283712084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty