Provider Demographics
NPI:1790784502
Name:GREENBERG, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GREENBERG
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 1:7139 166TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3235
Mailing Address - Country:US
Mailing Address - Phone:718-380-1173
Mailing Address - Fax:212-685-1452
Practice Address - Street 1:30 E 40TH ST RM 607
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1201
Practice Address - Country:US
Practice Address - Phone:212-689-1331
Practice Address - Fax:212-685-1452
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142512207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00829745Medicaid
NY11D121Medicare PIN
NY04888Medicare PIN
NY00829745Medicaid