Provider Demographics
NPI:1578946182
Name:GREENE, TIMOTHY (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28078 BAXTER RD STE 424
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-1404
Mailing Address - Country:US
Mailing Address - Phone:951-679-1020
Mailing Address - Fax:951-679-5844
Practice Address - Street 1:28078 BAXTER RD STE 424
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1404
Practice Address - Country:US
Practice Address - Phone:951-679-1020
Practice Address - Fax:951-679-5844
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006662213ES0103X
CAE5511213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery