Provider Demographics
NPI:1346335692
Name:MORTIMER, JOANNE CLARAGE (MD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:CLARAGE
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JOANNE
Other - Middle Name:MORTIMER
Other - Last Name:DRAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13800 SHAKER BLVD
Mailing Address - Street 2:#804
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1584
Mailing Address - Country:US
Mailing Address - Phone:216-751-8665
Mailing Address - Fax:
Practice Address - Street 1:8819 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-3445
Practice Address - Country:US
Practice Address - Phone:216-721-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.053356208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA16381Medicare UPIN