Provider Demographics
NPI:1750375184
Name:MORTIMER, JAMES PATRICK (DO)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:PATRICK
Last Name:MORTIMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:PATRICK
Other - Last Name:MORTIMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:200 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-9244
Mailing Address - Country:US
Mailing Address - Phone:336-846-0805
Mailing Address - Fax:
Practice Address - Street 1:200 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9244
Practice Address - Country:US
Practice Address - Phone:336-846-0805
Practice Address - Fax:336-846-0746
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023-01374208000000X
PAOS010009L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1255054623Medicaid
PA0018648750002Medicaid