Provider Demographics
NPI:1629056536
Name:EDELSTEIN, LEE WICHNER (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:WICHNER
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 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:866-234-8534
Mailing Address - Fax:
Practice Address - Street 1:305 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4015
Practice Address - Country:US
Practice Address - Phone:866-234-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75376208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254527600Medicaid