Provider Demographics
NPI:1124008586
Name:GREENBERG, MARK L (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 N MIDDLETOWN RD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-1188
Mailing Address - Country:US
Mailing Address - Phone:845-735-5757
Mailing Address - Fax:
Practice Address - Street 1:275 N MIDDLETOWN RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-1188
Practice Address - Country:US
Practice Address - Phone:845-735-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY90603OtherAETNA
NY1C7777OtherHEALTHNET
NYP835132OtherOXFORD
NYC26312OtherBCBS
NY132884816OtherTAX ID NUMBER
NYC26311Medicare PIN
NYC26312OtherBCBS
NY1C7777OtherHEALTHNET