MEDICARE: DR. DAVID D MORTENSEN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0601800582	VA
2	152W00000X	Optometrist	361378-9934	UT
3	152W00000X	Optometrist	18003429 A & B	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	162686	OTHER	VA	ANTHEM BLUE CROSS
2	P00190241	OTHER	VA	PALMETTO RAILROAD MEDICAR
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871590430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID D MORTENSEN OD

Provider Business Mailing Address
First Line	:	2028 W 2220 N
Second Line	:
City	:	CLINTON
State	:	UT
Zip	:	84015-5744
Country	:	US
Telephone Number	:	801-779-0708
Fax Number	:	385-393-7875

Provider Business Practice Location Address
First Line	:	2028 W 2220 N
Second Line	:
City	:	CLINTON
State	:	UT
Zip	:	84015-5744
Country	:	US
Telephone Number	:	801-779-0708
Fax Number	:	385-393-7875

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	10/24/2024

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