Provider Demographics
NPI:1437213451
Name:BORTNICK, KENNETH ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:BORTNICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7311 E RANIER DR
Mailing Address - Street 2:
Mailing Address - City:PARSONSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21849-2505
Mailing Address - Country:US
Mailing Address - Phone:410-546-1369
Mailing Address - Fax:410-546-5987
Practice Address - Street 1:800 K SOUTH SALISBURY BLVD.
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:410-546-1369
Practice Address - Fax:410-546-5987
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTAO709152W00000X
VA0601000758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist