Provider Demographics
NPI:1700012069
Name:GREENLY, IRWIN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:IRWIN
Middle Name:DAVID
Last Name:GREENLY
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 1:85 NORTH AVE
Mailing Address - Street 2:#1A
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5539
Mailing Address - Country:US
Mailing Address - Phone:415-499-0661
Mailing Address - Fax:
Practice Address - Street 1:85 NORTH AVE
Practice Address - Street 2:#1A
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-5539
Practice Address - Country:US
Practice Address - Phone:415-499-0661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30694207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine