Individual
MARK IDSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
9100 W 74TH ST, SHAWNEE MISSION, KS 66204-4004
(913) 676-2310
Mailing address
9212 NIEMAN RD, OVERLAND PARK, KS 66214-1868
(913) 599-6777
(913) 599-3955
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
R2J97
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
15144081
BCBS
—
Enumeration date
10/04/2006
Last updated
07/08/2007
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