Healthcare Provider Details

I. General information

NPI: 1760619365
Provider Name (Legal Business Name): DAMON SCOTT MORTENSEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 E 1ST S
REXBURG ID
83440-1966
US

IV. Provider business mailing address

49 E 1ST S
REXBURG ID
83440-1966
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4444
  • Fax: 208-356-4445
Mailing address:
  • Phone: 208-356-4444
  • Fax: 208-356-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100185
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: