Provider Demographics
NPI:1043219967
Name:GREENBERG, MARK LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOUIS
Last Name:GREENBERG
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 1:727 E BETHANY HOME RD
Mailing Address - Street 2:SUITE A-101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2198
Mailing Address - Country:US
Mailing Address - Phone:602-561-0367
Mailing Address - Fax:
Practice Address - Street 1:727 E BETHANY HOME RD
Practice Address - Street 2:SUITE A-101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2198
Practice Address - Country:US
Practice Address - Phone:602-561-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21921208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200260860Medicaid
AZ418677Medicaid
F04391Medicare UPIN