Provider Demographics
NPI:1356308530
Name:BORTNICK, DAVID M (PHD PSYD ABN)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:BORTNICK
Suffix:
Gender:M
Credentials:PHD PSYD ABN
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 TREE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5719
Practice Address - Country:US
Practice Address - Phone:904-342-0672
Practice Address - Fax:904-342-0673
Is Sole Proprietor?:No
Enumeration Date:2006-04-30
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2065103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75104OtherBCBS FL
FL75104Medicare ID - Type Unspecified