MEDICARE: MARK L MANSFIELD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	M-6799	ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	080179524	OTHER	ID	RR MEDICARE PROVIDER NUMB

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010000246	OTHER	ID	BLUE SHIELD PROVIDER NUMB
3	DI726	OTHER	ID	BLUE CROSS PROVIDER NUMBE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134113251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK L MANSFIELD M.D.

Provider Business Mailing Address
First Line	:	110 VISTA DR
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-5824
Country	:	US
Telephone Number	:	208-234-2300
Fax Number	:	208-234-0026

Provider Business Practice Location Address
First Line	:	110 VISTA DR
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-5824
Country	:	US
Telephone Number	:	208-234-2300
Fax Number	:	208-234-0026

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	01/07/2014

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Directions to “ MARK L MANSFIELD M.D.” Practice Location

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