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General NPI Number Information
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NPI Number | 1003818576
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Entity Type | Individual
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Provider Name | RYAN J MORTENSEN O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/12/2005
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Last Update Date | 01/07/2016
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Provider Practice Location Address
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Address Line | 11506 S DISTRICT DR STE 400
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-5769
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Country | US
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Telephone | 801-495-4833
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Fax | 801-495-4836
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Provider Business Mailing Address
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Address Line | 11506 S DISTRICT DR STE 400
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-5769
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Country | US
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Telephone | 801-495-4833
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Fax | 801-495-4836
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 5898711-9934
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License Number State | UT
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