Provider Demographics
NPI:1730155987
Name:EDELSTEIN, GARY STEVEN (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:STEVEN
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-2432
Mailing Address - Country:US
Mailing Address - Phone:856-779-7595
Mailing Address - Fax:856-779-7596
Practice Address - Street 1:38 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-2432
Practice Address - Country:US
Practice Address - Phone:856-779-7595
Practice Address - Fax:856-779-7596
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ 4996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3416405OtherCIGNA
NJ35237OtherDAVIS VISION
NJ132507OtherCOLE VISION
NJNJ84996OtherVISION BENEFITS AMERICA
NJ26010OtherAMERICHOICE
NJ26010OtherSPECTERA
NJ2K1495OtherHEALTH NET
NJ0604402Medicaid
NJ5548003OtherAETNA
NJNJ 4996OtherEYEMED VISION
NJ014929001OtherMDCR DMERC
NJ0402335000OtherAMERIHEALTH/KEYSTONE HMO
NJ580720OtherBC/BS PA
0149290001Medicare NSC
NJNJ84996OtherVISION BENEFITS AMERICA
NJ2K1495OtherHEALTH NET