Provider Demographics
NPI:1568572170
Name:EDELSON, TODD A (DPT DIP MDT)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:A
Last Name:EDELSON
Suffix:
Gender:M
Credentials:DPT DIP MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 SOUTH PARK STREET
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042
Mailing Address - Country:US
Mailing Address - Phone:973-744-9098
Mailing Address - Fax:973-744-3799
Practice Address - Street 1:47 SOUTH PARK STREET
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:973-744-9098
Practice Address - Fax:973-744-3799
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA02640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ675748RGGMedicare ID - Type Unspecified