Provider Demographics
NPI:1457508947
Name:MORTIMER, GERALD ELBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ELBERT
Last Name:MORTIMER
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 1:2095 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6705
Mailing Address - Country:US
Mailing Address - Phone:208-529-2235
Mailing Address - Fax:
Practice Address - Street 1:2095 HEATHER LN
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6705
Practice Address - Country:US
Practice Address - Phone:208-529-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3709207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology