Provider Demographics
NPI:1477591535
Name:MORTENSEN, ANNE MACKENZIE (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MACKENZIE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2937
Mailing Address - Country:US
Mailing Address - Phone:321-843-3220
Mailing Address - Fax:321-843-3210
Practice Address - Street 1:51 PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2937
Practice Address - Country:US
Practice Address - Phone:321-843-3220
Practice Address - Fax:321-843-3210
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067210208000000X
FLME165327208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120531200Medicaid
MI4234723-10Medicaid