Provider Demographics
NPI:1962473595
Name:MORTENSON, STEVEN WORTHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:WORTHEN
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3192 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6610
Mailing Address - Country:US
Mailing Address - Phone:928-778-3950
Mailing Address - Fax:
Practice Address - Street 1:3192 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6610
Practice Address - Country:US
Practice Address - Phone:928-778-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22728207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF21292Medicare UPIN
AZZWMBTLMedicare PIN