Provider Demographics
NPI:1457357626
Name:VON IDERSTINE, MARTIN ROBERT
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ROBERT
Last Name:VON IDERSTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1800
Mailing Address - Country:US
Mailing Address - Phone:763-533-6775
Mailing Address - Fax:763-535-2850
Practice Address - Street 1:4600 LAKE RD
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-1800
Practice Address - Country:US
Practice Address - Phone:763-533-6775
Practice Address - Fax:763-535-2850
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic