Provider Demographics
NPI:1275622094
Name:EDELSTEIN, MICHAEL MARVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MARVIN
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 RIDGEFORD DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4818
Mailing Address - Country:US
Mailing Address - Phone:818-707-9778
Mailing Address - Fax:818-874-3655
Practice Address - Street 1:3460 RIDGEFORD DR
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4818
Practice Address - Country:US
Practice Address - Phone:818-707-9778
Practice Address - Fax:818-874-3655
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0091072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000G91070Medicaid
CA000G91070OtherBLUE SHIELD
CA000G91070Medicaid
CAEF165YMedicare PIN