Provider Demographics
NPI:1871505776
Name:EDELMUTH, EVELYN R (MD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:R
Last Name:EDELMUTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:1501 CLAUS RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9711
Practice Address - Country:US
Practice Address - Phone:209-557-6310
Practice Address - Fax:209-557-6388
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA421382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA85758Medicare UPIN