Provider Demographics
NPI:1497765069
Name:EDELSTEIN, HOWARD ELLIS (MD)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:ELLIS
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 1:1411 E 31ST STREET
Mailing Address - Street 2:OAKCARE MEDICAL GROUP
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1080
Mailing Address - Country:US
Mailing Address - Phone:510-437-4323
Mailing Address - Fax:510-437-5042
Practice Address - Street 1:1411 E 31ST STREET
Practice Address - Street 2:OAKCARE MEDICAL GROUP
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1080
Practice Address - Country:US
Practice Address - Phone:510-437-4323
Practice Address - Fax:510-437-5042
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG050259207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G0502590Medicaid
F14486Medicare UPIN
CA00G0502590Medicare ID - Type Unspecified