Provider Demographics
NPI:1629018122
Name:GREENBERG, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:700 OLYMPIC PLAZA CIR
Mailing Address - Street 2:STE 700
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1951
Mailing Address - Country:US
Mailing Address - Phone:903-262-3900
Mailing Address - Fax:903-262-3993
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:STE 700
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1951
Practice Address - Country:US
Practice Address - Phone:903-262-3900
Practice Address - Fax:903-262-3993
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7757208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131867701Medicaid
TX131867701Medicaid
TX88V170Medicare PIN