Provider Demographics
NPI:1295146348
Name:MORTISON, EUGENE (MD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:MORTISON
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 1:4350 KAI IKENA DR
Mailing Address - Street 2:
Mailing Address - City:KALAHEO
Mailing Address - State:HI
Mailing Address - Zip Code:96741-9580
Mailing Address - Country:US
Mailing Address - Phone:646-760-6131
Mailing Address - Fax:
Practice Address - Street 1:171 W 79TH ST STE 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6449
Practice Address - Country:US
Practice Address - Phone:646-760-6131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2816922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry