Provider Demographics
NPI:1124223482
Name:GREENWALD, ROGER A (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:GREENWALD
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 1:909 SAN RAMON VALLEY BLVD
Mailing Address - Street 2:#114
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4038
Mailing Address - Country:US
Mailing Address - Phone:925-837-6428
Mailing Address - Fax:925-837-1403
Practice Address - Street 1:909 SAN RAMON VALLEY BLVD
Practice Address - Street 2:#114
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4038
Practice Address - Country:US
Practice Address - Phone:925-837-6428
Practice Address - Fax:925-837-1403
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC335960207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OOC335960Medicare ID - Type Unspecified
CAA35323Medicare UPIN