Provider Demographics
NPI:1932216124
Name:MORTARA, LAURIE A (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:MORTARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 N BELLFLOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3126
Mailing Address - Country:US
Mailing Address - Phone:562-346-2222
Mailing Address - Fax:
Practice Address - Street 1:2110 N BELLFLOWER BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3126
Practice Address - Country:US
Practice Address - Phone:562-346-2222
Practice Address - Fax:562-546-8268
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64673207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHC716ZMedicare PIN
F61837Medicare UPIN