Provider Demographics
NPI:1518937382
Name:EDSTROM, MARK EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWIN
Last Name:EDSTROM
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:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:1400 BELLINGER ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5222
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30517300Medicaid
WI30517300Medicaid
B52584Medicare UPIN