Provider Demographics
NPI:1689780793
Name:GREENBERG, JODY M (DPM)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:M
Last Name:GREENBERG
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:PO BOX 4557
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92690
Mailing Address - Country:US
Mailing Address - Phone:949-624-1117
Mailing Address - Fax:
Practice Address - Street 1:27262 ESGOS
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-3301
Practice Address - Country:US
Practice Address - Phone:949-624-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3149213E00000X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E31490Medicaid
CA480027973OtherRAILROAD MEDICARE
CA126213600OtherDEPT OF LABOR US
CA480027973OtherRAILROAD MEDICARE
T19278Medicare UPIN
CA000E31490Medicaid