Provider Demographics
NPI:1881778413
Name:BENGTSON, MARK B (MPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:B
Last Name:BENGTSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 E GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7932
Mailing Address - Country:US
Mailing Address - Phone:208-765-0799
Mailing Address - Fax:
Practice Address - Street 1:1590 E POLSTON AVE STE B
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5218
Practice Address - Country:US
Practice Address - Phone:208-777-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-1703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1655877Medicare PIN