Provider Demographics
NPI:1861691552
Name:MORTLOCK, DAVID H
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:H
Last Name:MORTLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 VALLEY VIEW BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-2040
Mailing Address - Country:US
Mailing Address - Phone:540-265-1607
Mailing Address - Fax:540-366-7353
Practice Address - Street 1:4910 VALLEY VIEW BLVD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-2040
Practice Address - Country:US
Practice Address - Phone:540-265-1607
Practice Address - Fax:540-366-7353
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA116019067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861691552Medicaid
VAVAA101753Medicare PIN