Healthcare Provider Details

I. General information

NPI: 1215926845
Provider Name (Legal Business Name): CATHY DIANE SANDSTROM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6148 N DISCOVERY WAY SUITE 100
BOISE ID
83713-0201
US

IV. Provider business mailing address

6148 N DISCOVERY WAY SUITE 100
BOISE ID
83713-0201
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-5437
  • Fax: 208-322-4638
Mailing address:
  • Phone: 208-322-5437
  • Fax: 208-322-4638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM5331
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: