Provider Demographics
NPI:1568521862
Name:BORTNICK, RONALD JACK (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:JACK
Last Name:BORTNICK
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 1:3301 WOODBURN RD
Mailing Address - Street 2:209
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003
Mailing Address - Country:US
Mailing Address - Phone:703-573-1144
Mailing Address - Fax:703-641-0503
Practice Address - Street 1:3301 WOODBURN RD
Practice Address - Street 2:209
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003
Practice Address - Country:US
Practice Address - Phone:703-573-1144
Practice Address - Fax:703-641-0503
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101016725207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B93645Medicare UPIN
143512Medicare ID - Type Unspecified