Provider Demographics
NPI:1487679577
Name:EDELMAN, MARTIN (PHD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:EDELMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3424
Mailing Address - Country:US
Mailing Address - Phone:800-275-3243
Mailing Address - Fax:800-275-3671
Practice Address - Street 1:5110 12TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3424
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:800-275-3671
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005589103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00665494Medicaid
NYVS144V5761Medicare PIN
NY00665494Medicaid