Provider Demographics
NPI:1376504662
Name:EDELENBOS, ERIC J (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:EDELENBOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 HUNTERS CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6901
Mailing Address - Country:US
Mailing Address - Phone:407-857-2502
Mailing Address - Fax:407-857-1855
Practice Address - Street 1:3000 HUNTERS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6901
Practice Address - Country:US
Practice Address - Phone:407-857-2502
Practice Address - Fax:407-857-1855
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9412207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273408700Medicaid
FL273408700Medicaid
FL16938ZMedicare PIN