Provider Demographics
NPI:1033104666
Name:GREENBERG, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:S
Other - Last Name:GREENBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:400 W LBJ FWY STE 330
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3717
Mailing Address - Country:US
Mailing Address - Phone:972-556-2885
Mailing Address - Fax:972-506-8733
Practice Address - Street 1:400 W LBJ FWY STE 330
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3717
Practice Address - Country:US
Practice Address - Phone:972-556-2885
Practice Address - Fax:972-506-8733
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0399174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMDH0399OtherWK COMP
TX89290BOtherBCBS OF TX
TXE68286Medicare UPIN
TXMDH0399OtherWK COMP