Provider Demographics
NPI:1912426115
Name:EDELSTEIN, PETER SETH (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:SETH
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 1:1347 ELYSIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-7027
Mailing Address - Country:US
Mailing Address - Phone:352-459-2552
Mailing Address - Fax:
Practice Address - Street 1:305 N MANGOUSTINE AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1004
Practice Address - Country:US
Practice Address - Phone:321-283-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME137854208600000X
CAG065141208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty