Provider Demographics
NPI:1013937069
Name:MORTARA, RONALD W (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:W
Last Name:MORTARA
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 1:353 WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-2027
Mailing Address - Country:US
Mailing Address - Phone:617-964-4341
Mailing Address - Fax:617-964-1023
Practice Address - Street 1:353 WOODWARD ST
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-2027
Practice Address - Country:US
Practice Address - Phone:617-964-4341
Practice Address - Fax:617-964-1023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45935207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE05266Medicare ID - Type Unspecified
A54589Medicare UPIN