Provider Demographics
NPI:1750374625
Name:EDINBERG, MARK A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:EDINBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 MARNE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1752
Mailing Address - Country:US
Mailing Address - Phone:203-335-5497
Mailing Address - Fax:203-335-5497
Practice Address - Street 1:145 MARNE AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-1752
Practice Address - Country:US
Practice Address - Phone:203-254-8372
Practice Address - Fax:203-335-5497
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT748103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4100484Medicaid
CT4100484Medicaid
CTD300043869Medicare PIN