Provider Demographics
NPI:1366465460
Name:GREENBERG, JACK J (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:J
Last Name:GREENBERG
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:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-262-7963
Mailing Address - Fax:505-232-1627
Practice Address - Street 1:2121 JUAN TABO NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112
Practice Address - Country:US
Practice Address - Phone:505-237-8800
Practice Address - Fax:505-237-8803
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30775Medicaid
NM30775Medicaid