Basic Information
| Provider Information | |||||||||
| NPI: | 1679825400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 NORTH UNIVERSITY BOULEVARD: SET. 0641 | ||||||||
| Address2: | INDIANA UNIVERSITY HOSPITAL | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179441816 | ||||||||
| FaxNumber: | 3179482803 | ||||||||
| Practice Location | |||||||||
| Address1: | 842 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416185825 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | DO187083 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.