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General NPI Number Information
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NPI Number | 1194253682
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Entity Type | Individual
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Provider Name | NATHAN CODY MORTENSEN OD
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Gender | Male
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Dates
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Enumeration Date | 05/26/2017
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Last Update Date | 05/26/2017
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Provider Practice Location Address
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Address Line | 49 E 1ST S
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City | REXBURG
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State | ID
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Zip | 83440-1966
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Country | US
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Telephone | 208-356-4444
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Fax |
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Provider Business Mailing Address
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Address Line | 1340 FAIRVIEW AVE
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City | REXBURG
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State | ID
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Zip | 83440-5078
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Country | US
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Telephone | 208-351-4170
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Fax |
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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 | 100403
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License Number State | ID
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