Provider Demographics
NPI:1134113251
Name:MANSFIELD, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MANSFIELD
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 1:110 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5824
Mailing Address - Country:US
Mailing Address - Phone:208-234-2300
Mailing Address - Fax:208-234-0026
Practice Address - Street 1:110 VISTA DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5824
Practice Address - Country:US
Practice Address - Phone:208-234-2300
Practice Address - Fax:208-234-0026
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000246OtherBLUE SHIELD PROVIDER NUMB
ID080179524OtherRR MEDICARE PROVIDER NUMB
IDDI726OtherBLUE CROSS PROVIDER NUMBE
ID804222200Medicaid
IDG23637Medicare UPIN
ID1133472Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER