Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 105826 | MO |
Y | 207K00000X | Allergist & Immunologist | 25074 | KS |
NPI | 1063449288 |
---|---|
Provider Name | Dr. Mark R Neustrom |
First Address | Overland Park, KS 66210 |
Second Address | Overland Park, KS 66210 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E54975 | (02) |