Provider Demographics
NPI:1043296213
Name:EDELSTEIN, MICHAEL K (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:K
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:446 MOODY ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-0415
Practice Address - Country:US
Practice Address - Phone:781-899-3200
Practice Address - Fax:781-894-4645
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2402152W00000X
MA2402TP152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0322121Medicaid
MAW16223OtherBLUE CROSS
T59223Medicare UPIN
MAW16223OtherBLUE CROSS