Provider Demographics
NPI:1386616852
Name:EDELSON, KENNETH L (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:EDELSON
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 1:112 E 84TH ST
Mailing Address - Street 2:#1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0901
Mailing Address - Country:US
Mailing Address - Phone:212-744-4800
Mailing Address - Fax:212-744-4808
Practice Address - Street 1:112 E 84TH ST
Practice Address - Street 2:#1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0901
Practice Address - Country:US
Practice Address - Phone:212-744-4800
Practice Address - Fax:212-744-4808
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116745207N00000X, 207NI0002X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B13421Medicare UPIN
341471Medicare ID - Type Unspecified