Healthcare Provider Details

I. General information

NPI: 1629056536
Provider Name (Legal Business Name): LEE WICHNER EDELSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W CENTRAL AVE
LAKE WALES FL
33853-4015
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 866-234-8534
  • Fax:
Mailing address:
  • Phone: 866-234-8534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME75376
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: