Provider Demographics
NPI:1699786996
Name:MORTENS, MARTIN (DO)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MORTENS
Suffix:
Gender:M
Credentials:DO
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-270-1177
Mailing Address - Fax:515-643-9361
Practice Address - Street 1:6200 AURORA AVE
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2800
Practice Address - Country:US
Practice Address - Phone:515-270-1177
Practice Address - Fax:515-643-9361
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2125005Medicaid
IA06865Medicare ID - Type Unspecified
IA2125005Medicaid