Provider Demographics
NPI:1417954918
Name:MORTINSEN, ROY L (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:L
Last Name:MORTINSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-4539
Mailing Address - Fax:605-328-4531
Practice Address - Street 1:20 S PLUM ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-3346
Practice Address - Country:US
Practice Address - Phone:605-624-9111
Practice Address - Fax:605-624-6636
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5066207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5611220Medicaid
SD5611220Medicaid
SDS40432Medicare PIN
SDS40446Medicare PIN
SD080188684Medicare PIN