Provider Demographics
NPI:1619961224
Name:EDELSTEIN, MARTIN PETER (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:PETER
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 1:11 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1320
Mailing Address - Country:US
Mailing Address - Phone:516-487-1614
Mailing Address - Fax:516-487-8343
Practice Address - Street 1:11 BEVERLY RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1320
Practice Address - Country:US
Practice Address - Phone:516-487-1614
Practice Address - Fax:516-487-8343
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130193173000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCO4538Medicare UPIN