Provider Demographics
NPI:1104879089
Name:EDELSOHN, DAVID ALAN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
Last Name:EDELSOHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:A
Other - Last Name:EDELSOHN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, INC
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:2160 W GRANT LINE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7330
Practice Address - Country:US
Practice Address - Phone:209-836-5680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37480207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A374800Medicaid
CA00A374800Medicaid
A28384Medicare UPIN
CA050002069Medicare PIN
CAAU821YMedicare PIN