Provider Demographics
NPI:1326023466
Name:GREENWALD, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
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 1:50 STANIFORD ST
Mailing Address - Street 2:SUITE 503B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2517
Mailing Address - Country:US
Mailing Address - Phone:617-643-6408
Mailing Address - Fax:
Practice Address - Street 1:50 STANIFORD ST
Practice Address - Street 2:SUITE 503B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2517
Practice Address - Country:US
Practice Address - Phone:617-643-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3191613Medicaid
MA3191613Medicaid
MAG87875Medicare UPIN