Provider Demographics
NPI:1437200714
Name:MORTENSEN, TODD PHILIP (DC)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:PHILIP
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 N WISCONSIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1318
Mailing Address - Country:US
Mailing Address - Phone:262-723-3235
Mailing Address - Fax:232-723-8621
Practice Address - Street 1:422 N WISCONSIN ST STE A
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1318
Practice Address - Country:US
Practice Address - Phone:262-723-3235
Practice Address - Fax:262-723-8621
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3859-012111N00000X
MN4229111N00000X
IL38010724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38943900Medicaid
WI39004100Medicaid
WI38943900Medicaid
WI000035821Medicare ID - Type UnspecifiedKMHW GROUP NUMBER
WIU94587Medicare UPIN