Healthcare Provider Details

I. General information

NPI: 1447660931
Provider Name (Legal Business Name): DANIEL MORTENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 MICHIGAN AVE
HOLLAND MI
49423-4918
US

IV. Provider business mailing address

PO BOX 1012
NEWAYGO MI
49337-1012
US

V. Phone/Fax

Practice location:
  • Phone: 616-392-5141
  • Fax:
Mailing address:
  • Phone: 231-652-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301105002
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301105002
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: