Provider Demographics
NPI:1437225950
Name:MORTENSEN, ERIC JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:MORTENSEN
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 1:300 SOUTH ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89501-2002
Mailing Address - Country:US
Mailing Address - Phone:775-348-1900
Mailing Address - Fax:775-348-1904
Practice Address - Street 1:235 W 6TH STREET
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4548
Practice Address - Country:US
Practice Address - Phone:775-770-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5270207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C96379Medicare UPIN
05WCGVN21Medicare ID - Type Unspecified