Provider Demographics
NPI:1568716744
Name:MORTENSEN, SPENCER LEWIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:LEWIS
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DPM
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Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-812-7215
Mailing Address - Fax:501-812-7207
Practice Address - Street 1:1500 DODSON AVE STE 260
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5179
Practice Address - Country:US
Practice Address - Phone:479-573-7905
Practice Address - Fax:479-573-7906
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5587758-0501213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
66879078Medicare PIN