Provider Demographics
NPI:1871590430
Name:MORTENSEN, DAVID D (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:D
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 W 2220 N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-5744
Mailing Address - Country:US
Mailing Address - Phone:801-779-0708
Mailing Address - Fax:385-393-7875
Practice Address - Street 1:2028 W 2220 N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-5744
Practice Address - Country:US
Practice Address - Phone:801-779-0708
Practice Address - Fax:385-393-7875
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601800582152W00000X
UT361378-9934152W00000X
IN18003429 A & B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA162686OtherANTHEM BLUE CROSS
VAP00190241OtherPALMETTO RAILROAD MEDICAR
VA010118166Medicaid
VA005988C97Medicare ID - Type Unspecified