Provider Demographics
NPI:1780643015
Name:GREENBERG, JERRY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3501 E SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3917
Mailing Address - Country:US
Mailing Address - Phone:520-833-5171
Mailing Address - Fax:520-318-7107
Practice Address - Street 1:6565 E CARONDELET DR STE 155
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3587
Practice Address - Country:US
Practice Address - Phone:520-849-8900
Practice Address - Fax:520-849-7137
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21528174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF08594Medicare UPIN
AZ117662Medicare PIN