Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | MN |
NPI | 1457357626 |
---|---|
Provider Name | Dr. Martin Robert Von Iderstine |
First Address | Robbinsdale, MN 55422-1800 |
Second Address | Robbinsdale, MN 55422-1800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2005 |
Last Update Date | 08/07/2007 |