Provider Demographics
NPI:1699850966
Name:EDLUND, MARK JAMES (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:EDLUND
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5022
Mailing Address - Country:US
Mailing Address - Phone:208-734-6760
Mailing Address - Fax:
Practice Address - Street 1:228 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5022
Practice Address - Country:US
Practice Address - Phone:208-734-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-32752084P0800X
IDM-101082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry