Provider Demographics
NPI:1518024520
Name:MORTENSEN, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:800 MERCY DR
Mailing Address - Street 2:STE 220
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3128
Mailing Address - Country:US
Mailing Address - Phone:712-388-2660
Mailing Address - Fax:712-388-2665
Practice Address - Street 1:800 MERCY DR STE 220
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3128
Practice Address - Country:US
Practice Address - Phone:712-388-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35976208600000X
NE26750208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I14848Medicare ID - Type Unspecified
I26816Medicare UPIN