Provider Demographics
NPI:1922081645
Name:MORTENSEN, NEAL R (DPM)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:R
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W CENTRAL PKWY STE 1000
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2433
Mailing Address - Country:US
Mailing Address - Phone:321-397-2699
Mailing Address - Fax:407-926-0500
Practice Address - Street 1:450 W CENTRAL PKWY STE 1000
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2433
Practice Address - Country:US
Practice Address - Phone:321-397-2699
Practice Address - Fax:407-926-0500
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3214213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65910OtherBLUE CROSS BLUE SHIELD
FL340549400Medicaid
FLU56525Medicare UPIN
FL65910ZMedicare Oscar/Certification