Healthcare Provider Details

I. General information

NPI: 1457357626
Provider Name (Legal Business Name): DR. MARTIN ROBERT VON IDERSTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 LAKE RD
ROBBINSDALE MN
55422-1800
US

IV. Provider business mailing address

4600 LAKE RD
ROBBINSDALE MN
55422-1800
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-6775
  • Fax: 763-535-2850
Mailing address:
  • Phone: 763-533-6775
  • Fax: 763-535-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: