Provider Demographics
NPI:1760473680
Name:DOLMAN, MORTIMER (MD)
Entity type:Individual
Prefix:DR
First Name:MORTIMER
Middle Name:
Last Name:DOLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 LAUREL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-2100
Mailing Address - Country:US
Mailing Address - Phone:614-471-5404
Mailing Address - Fax:
Practice Address - Street 1:175 W JOHNSTOWN RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-5714
Practice Address - Country:US
Practice Address - Phone:614-471-9788
Practice Address - Fax:614-471-4733
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35032208207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0130263Medicaid
110013855Medicare PIN
OH0151982Medicare PIN
OH0130263Medicaid