Provider Demographics
NPI:1164422085
Name:EDELSTEIN, MITCHELL E
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:E
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 E BELL RD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2138
Mailing Address - Country:US
Mailing Address - Phone:602-494-5040
Mailing Address - Fax:602-494-4020
Practice Address - Street 1:3811 E BELL RD
Practice Address - Street 2:SUITE 309
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2138
Practice Address - Country:US
Practice Address - Phone:602-494-5040
Practice Address - Fax:602-494-4020
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C98212Medicare UPIN
72901Medicare ID - Type Unspecified