Provider Demographics
NPI:1548321078
Name:MORTENSEN, SPENCER DAVID (OD, FAAO)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:DAVID
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 E 100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1802
Mailing Address - Country:US
Mailing Address - Phone:801-532-5176
Mailing Address - Fax:801-532-5179
Practice Address - Street 1:462 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1802
Practice Address - Country:US
Practice Address - Phone:801-532-5176
Practice Address - Fax:801-532-5179
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109072-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000009585Medicare ID - Type UnspecifiedMEDICARE ID
UTT78150Medicare UPIN