Healthcare Provider Details

I. General information

NPI: 1699850966
Provider Name (Legal Business Name): MARK JAMES EDLUND MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 SHOUP AVE W
TWIN FALLS ID
83301-5022
US

IV. Provider business mailing address

228 SHOUP AVE W
TWIN FALLS ID
83301-5022
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-6760
  • Fax:
Mailing address:
  • Phone: 208-734-6760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberE-3275
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-10108
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: