Basic Information
| Provider Information | |||||||||
| NPI: | 1356555775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | D | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORTENSEN | ||||||||
| OtherFirstName: | D | ||||||||
| OtherMiddleName: | KILEY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1236 E ELIZABETH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702242985 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1236 E ELIZABETH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702242985 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | DR.0053822 | CO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 137456700 | 05 | WY | MEDICAID | 90002075 | 05 | CO | MEDICAID | P01378144 | 01 | CO | RR MEDICARE | OTHER |