Provider Demographics
NPI:1467604025
Name:MORTIMER, DALE BURTON (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:BURTON
Last Name:MORTIMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 NE 7TH AVE
Mailing Address - Street 2:SUITE #385
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2955
Mailing Address - Country:US
Mailing Address - Phone:360-882-9058
Mailing Address - Fax:360-567-0861
Practice Address - Street 1:10000 NE 7TH AVE
Practice Address - Street 2:SUITE #385
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2955
Practice Address - Country:US
Practice Address - Phone:360-882-9058
Practice Address - Fax:360-567-0861
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000283712084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D86837Medicare UPIN