Healthcare Provider Details

I. General information

NPI: 1619961224
Provider Name (Legal Business Name): MARTIN PETER EDELSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BEVERLY RD
GREAT NECK NY
11021-1320
US

IV. Provider business mailing address

11 BEVERLY RD
GREAT NECK NY
11021-1320
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-1614
  • Fax: 516-487-8343
Mailing address:
  • Phone: 516-487-1614
  • Fax: 516-487-8343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number130193
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number130193
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: