Provider Demographics
NPI:1295832152
Name:EDELSON, RONALD JAY (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:JAY
Last Name:EDELSON
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 1:9339 GENESEE AVE STE P39
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2120
Mailing Address - Country:US
Mailing Address - Phone:858-452-9900
Mailing Address - Fax:858-455-1287
Practice Address - Street 1:9339 GENESEE AVE STE P39
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2120
Practice Address - Country:US
Practice Address - Phone:858-452-9900
Practice Address - Fax:858-455-1287
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59765208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G597650Medicaid
BEO193401OtherDEA
B58042Medicare UPIN
G59765Medicare ID - Type Unspecified