Provider Demographics
NPI:1427056860
Name:MORTENSON, BLAKE C (MD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:C
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:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1108
Mailing Address - Country:US
Mailing Address - Phone:801-296-2113
Mailing Address - Fax:801-296-1715
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:435-716-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT483759612052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118743100Medicaid
UTD4474Medicaid
ID806638500Medicaid
ID1107470Medicare PIN
G01709Medicare UPIN
UT005546907Medicare PIN
ID806638500Medicaid
UTP00023762Medicare PIN