Basic Information
| Provider Information | |||||||||
| NPI: | 1871505776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDELMUTH | ||||||||
| FirstName: | EVELYN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 STANDIFORD AVE | ||||||||
| Address2: | F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 CLAUS RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953559711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095576310 | ||||||||
| FaxNumber: | 2095576388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A42138 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.