Provider Demographics
NPI:1841579109
Name:EDSTROM, RICHARD EDWARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWARD
Last Name:EDSTROM
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:926 S COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2512
Mailing Address - Country:US
Mailing Address - Phone:631-286-6130
Mailing Address - Fax:631-286-6130
Practice Address - Street 1:926 S COUNTRY RD
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-2512
Practice Address - Country:US
Practice Address - Phone:631-286-6130
Practice Address - Fax:631-286-6130
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY170661207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease