Provider Demographics
NPI:1538112883
Name:MORTENSEN, MARTA R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTA
Middle Name:R
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8793 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-5111
Mailing Address - Country:US
Mailing Address - Phone:314-961-0900
Mailing Address - Fax:314-961-0909
Practice Address - Street 1:8793 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-5111
Practice Address - Country:US
Practice Address - Phone:314-961-0900
Practice Address - Fax:314-961-0909
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO102738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO005014518OtherFPH
MO205163306Medicaid
MO205163306Medicaid