Healthcare Provider Details

I. General information

NPI: 1386616852
Provider Name (Legal Business Name): KENNETH L EDELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E 84TH ST #1B
NEW YORK NY
10028-0901
US

IV. Provider business mailing address

112 E 84TH ST #1B
NEW YORK NY
10028-0901
US

V. Phone/Fax

Practice location:
  • Phone: 212-744-4800
  • Fax: 212-744-4808
Mailing address:
  • Phone: 212-744-4800
  • Fax: 212-744-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number116745
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number116745
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number116745
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: