Provider Demographics
NPI:1710047105
Name:EDELSTEIN, RICHARD D (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
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:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-0724
Mailing Address - Country:US
Mailing Address - Phone:802-334-6744
Mailing Address - Fax:802-334-7450
Practice Address - Street 1:154 DUCHESS STREET
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-0724
Practice Address - Country:US
Practice Address - Phone:802-334-6744
Practice Address - Fax:802-334-7450
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT4200070672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT508401OtherMEDICARE PTAN
VT0005084Medicaid
VT0005084Medicaid