Provider Demographics
NPI:1942461850
Name:MORTENSEN, JOSEPH M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 W 5TH AVE
Mailing Address - Street 2:SUITE #250E
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-4880
Mailing Address - Country:US
Mailing Address - Phone:866-263-1223
Mailing Address - Fax:509-835-4058
Practice Address - Street 1:1512 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6008
Practice Address - Country:US
Practice Address - Phone:866-263-1223
Practice Address - Fax:208-463-5081
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11657207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1942461850Medicaid
ID20001242Medicare PIN