Individual
BLAKE C. MORTENSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1400 N 500 E, LOGAN, UT 84341-2455
(435) 716-1000
Mailing address
PO BOX 1108, BOUNTIFUL, UT 84011-1108
(801) 296-2113
(801) 296-1715
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
48375961205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
118743100
—
WY
05
—
806638500
—
ID
05
—
D4474
—
UT
Enumeration date
07/11/2005
Last updated
04/20/2015
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