Provider Demographics
NPI:1326090259
Name:BORTNICK, DANIEL P (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:BORTNICK
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 1:11550 GRANADA ST
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1453
Mailing Address - Country:US
Mailing Address - Phone:913-754-4939
Mailing Address - Fax:913-663-2411
Practice Address - Street 1:11550 GRANADA ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1453
Practice Address - Country:US
Practice Address - Phone:913-754-4939
Practice Address - Fax:913-663-2411
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105608208200000X
KS0422406208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP73000009OtherMEDICARE KS
MOP73A00011OtherMEDICARE MO
KSP73000009OtherMEDICARE KS
KSG395627Medicare ID - Type Unspecified