Healthcare Provider Details

I. General information

NPI: 1871505776
Provider Name (Legal Business Name): EVELYN R. EDELMUTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CLAUS RD
MODESTO CA
95355-9711
US

IV. Provider business mailing address

220 STANDIFORD AVE F
MODESTO CA
95350-1159
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-6310
  • Fax: 209-557-6388
Mailing address:
  • Phone: 209-579-5628
  • Fax: 209-579-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA42138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: