Provider Demographics
NPI:1801881578
Name:MORTIMER, MICHAEL DALE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:MORTIMER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S UNION ST
Mailing Address - Street 2:STE. 8
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-9807
Mailing Address - Country:US
Mailing Address - Phone:716-372-8644
Mailing Address - Fax:716-373-4257
Practice Address - Street 1:130 S UNION ST
Practice Address - Street 2:STE. 8
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-9807
Practice Address - Country:US
Practice Address - Phone:716-372-8644
Practice Address - Fax:716-373-4257
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3906152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNY3906OtherEYEMED
NY00606964Medicaid
NY081471Medicare ID - Type Unspecified
NYNY3906OtherEYEMED
NY11897BMedicare ID - Type Unspecified