Provider Demographics
NPI:1598767600
Name:GREENBAUM, BRUCE ROY (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROY
Last Name:GREENBAUM
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 1:3000 OCEAN PKWY
Mailing Address - Street 2:APT 2G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8344
Mailing Address - Country:US
Mailing Address - Phone:718-265-2600
Mailing Address - Fax:718-265-0345
Practice Address - Street 1:3000 OCEAN PKWY
Practice Address - Street 2:APT 2G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8344
Practice Address - Country:US
Practice Address - Phone:718-265-2600
Practice Address - Fax:718-265-0345
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004557213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01190069Medicaid
NY01190069Medicaid
NYP51591Medicare ID - Type Unspecified
NY4582460001Medicare NSC