Provider Demographics
NPI:1922329606
Name:JAY C. MORTIMER, MD, A MEDICAL CORP.
Entity Type:Organization
Organization Name:JAY C. MORTIMER, MD, A MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORTIMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-995-8766
Mailing Address - Street 1:4419 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2910
Mailing Address - Country:US
Mailing Address - Phone:818-995-8766
Mailing Address - Fax:
Practice Address - Street 1:4419 VAN NUYS BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2910
Practice Address - Country:US
Practice Address - Phone:818-995-8766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty