Provider Demographics
NPI:1215926845
Name:SANDSTROM, CATHY DIANE (MD)
Entity type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:DIANE
Last Name:SANDSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6148 N DISCOVERY WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0201
Mailing Address - Country:US
Mailing Address - Phone:208-322-5437
Mailing Address - Fax:208-322-4638
Practice Address - Street 1:6148 N DISCOVERY WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0201
Practice Address - Country:US
Practice Address - Phone:208-322-5437
Practice Address - Fax:208-322-4638
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5331208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010005930OtherBLUE SHIELD
01338OtherBLUE CROSS OF ID
ID804257200Medicaid
01338OtherBLUE CROSS OF ID