Provider Demographics
NPI:1225333123
Name:DAVID M. BORTNICK, PHD. PSYD. PA
Entity Type:Organization
Organization Name:DAVID M. BORTNICK, PHD. PSYD. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:BORTNICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PSYD, PA
Authorized Official - Phone:352-390-6656
Mailing Address - Street 1:1130 SE 18TH PLACE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5422
Mailing Address - Country:US
Mailing Address - Phone:352-390-6656
Mailing Address - Fax:352-390-8756
Practice Address - Street 1:1130 SE 18TH PLACE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5422
Practice Address - Country:US
Practice Address - Phone:352-390-6656
Practice Address - Fax:352-390-8756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-24
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLPY2065103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEQ188AMedicare PIN