Provider Demographics
NPI:1679825400
Name:MORTENSEN, NATHAN THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMAS
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 NORTH UNIVERSITY BOULEVARD: SET. 0641
Mailing Address - Street 2:INDIANA UNIVERSITY HOSPITAL
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-944-1816
Mailing Address - Fax:317-948-2803
Practice Address - Street 1:842 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-618-5825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO1870832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
R202268OtherMEDICARE
OR500745314Medicaid