Provider Demographics
NPI: | 1356638068 |
---|---|
Name: | GREENWOOD, ROBERT FOSTER (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ROBERT |
Middle Name: | FOSTER |
Last Name: | GREENWOOD |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1060 GAFFNEY RD |
Mailing Address - Street 2: | #7400 |
Mailing Address - City: | FORT WAINWRIGHT |
Mailing Address - State: | AK |
Mailing Address - Zip Code: | 99703-5002 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 907-361-5957 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1060 GAFFNEY RD |
Practice Address - Street 2: | #7400 |
Practice Address - City: | FORT WAINWRIGHT |
Practice Address - State: | AK |
Practice Address - Zip Code: | 99703-5002 |
Practice Address - Country: | US |
Practice Address - Phone: | 907-361-5957 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-07-01 |
Last Update Date: | 2018-04-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AK | 130860 | 208M00000X, 207R00000X |
HI | 1530 | 208D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VAD000 | Medicare UPIN |