Provider Demographics
NPI:1265470595
Name:GREENBERG, LAURIE RAE (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:RAE
Last Name:GREENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:RAE
Other - Last Name:HERTZENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9339 GENESEE AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2121
Mailing Address - Country:US
Mailing Address - Phone:858-455-7520
Mailing Address - Fax:858-554-1312
Practice Address - Street 1:9339 GENESEE AVE
Practice Address - Street 2:STE 220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2121
Practice Address - Country:US
Practice Address - Phone:858-455-7520
Practice Address - Fax:858-554-1312
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66890207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330627190OtherFEDERAL TAX ID
CAWG66890Medicare ID - Type Unspecified
F11534Medicare UPIN