Provider Demographics
NPI:1033109210
Name:MORTARA, KEVIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:MORTARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1580 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5751
Mailing Address - Country:US
Mailing Address - Phone:920-435-8326
Mailing Address - Fax:920-430-4659
Practice Address - Street 1:1580 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5751
Practice Address - Country:US
Practice Address - Phone:920-435-8326
Practice Address - Fax:920-430-4659
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI48997-20207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400140496Medicare Oscar/Certification