Provider Demographics
NPI:1972516714
Name:EDELSTEIN, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
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 1:1933 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-4214
Mailing Address - Country:US
Mailing Address - Phone:916-442-4682
Mailing Address - Fax:
Practice Address - Street 1:1933 9TH AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-4214
Practice Address - Country:US
Practice Address - Phone:916-442-4682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC413402084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C41340(0)OtherMEDI-CAL PIN
CA1238OtherSAN JOAQUIN COUNTY MENTAL HEALTH DEPT.
CA1177OtherSACRAMENTO CY. PROVIDER #
CA1238OtherSAN JOAQUIN COUNTY MENTAL HEALTH DEPT.