Provider Demographics
NPI:1003818576
Name:MORTENSEN, RYAN J (OD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:11506 S DISTRICT DR
Mailing Address - Street 2:STE 400
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5769
Mailing Address - Country:US
Mailing Address - Phone:801-495-4833
Mailing Address - Fax:801-495-4836
Practice Address - Street 1:11506 S DISTRICT DR
Practice Address - Street 2:STE 400
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5769
Practice Address - Country:US
Practice Address - Phone:801-495-4833
Practice Address - Fax:801-495-4836
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-01-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT5898711-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist