Healthcare Provider Details

I. General information

NPI: 1972668531
Provider Name (Legal Business Name): MARY BETH OSTROM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 E 25TH ST
IDAHO FALLS ID
83404-7542
US

IV. Provider business mailing address

PO BOX 742358
ATLANTA GA
30374-2358
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM5589
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: