Provider Demographics
NPI:1760565402
Name:GREESON, SAMUEL DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DOUGLAS
Last Name:GREESON
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:
Practice Address - Street 1:7333 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6280
Practice Address - Country:US
Practice Address - Phone:260-458-3830
Practice Address - Fax:260-458-3831
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028597A207P00000X, 208100000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000646442OtherANTHEM PROVIDER NUMBER
IN100085750Medicaid
453220MMedicare PIN
IN100085750Medicaid
IN000000646442OtherANTHEM PROVIDER NUMBER