Provider Demographics
NPI:1225165335
Name:MORTENSON, MONICA (OD)
Entity type:Individual
Prefix:DR
First Name:MONICA
Middle Name:
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 29TH ST # 1E-1156
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1065
Mailing Address - Country:US
Mailing Address - Phone:720-565-0445
Mailing Address - Fax:720-565-0649
Practice Address - Street 1:1855 29TH ST # 1E-1156
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1065
Practice Address - Country:US
Practice Address - Phone:720-565-0445
Practice Address - Fax:720-565-0649
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12039T152W00000X
CO2573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist