Provider Demographics
NPI:1629158340
Name:GREENLEAF, EDWARD C (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:GREENLEAF
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 14
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0014
Mailing Address - Country:US
Mailing Address - Phone:209-481-8312
Mailing Address - Fax:209-475-1119
Practice Address - Street 1:2027 GRAND CANAL BLVD STE 25
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6650
Practice Address - Country:US
Practice Address - Phone:209-475-1111
Practice Address - Fax:209-475-1119
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG514882085R0001X, 2085R0203X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Not Answered2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G514880Medicaid
CAG51488OtherSTATE LICENSE
CA00G514880Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID #
CA00G514880Medicaid