Provider Demographics
NPI:1952415101
Name:BORTEL, BEAU G (DPM)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:G
Last Name:BORTEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 MONCLOVA RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-893-5757
Mailing Address - Fax:419-893-5399
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:SUITE 5
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-5757
Practice Address - Fax:419-893-5399
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003428213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2678697Medicaid
OHP00327423OtherRAILROAD MEDICARE
OH4180381Medicare PIN