Individual
MARK L MANSFIELD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
110 VISTA DR, POCATELLO, ID 83201-5824
(208) 234-2300
(208) 234-0026
Mailing address
110 VISTA DR, POCATELLO, ID 83201-5824
(208) 234-2300
(208) 234-0026
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M-6799
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010000246
BLUE SHIELD PROVIDER NUMB
ID
01
—
080179524
RR MEDICARE PROVIDER NUMB
ID
05
—
804222200
—
ID
01
—
DI726
BLUE CROSS PROVIDER NUMBE
ID
Enumeration date
09/02/2005
Last updated
01/07/2014
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