Provider Demographics
NPI:1790832137
Name:GREENBAUM, PAUL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOSEPH
Last Name:GREENBAUM
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 1:6609 BEAU CHENE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6500
Mailing Address - Country:US
Mailing Address - Phone:505-299-2193
Mailing Address - Fax:
Practice Address - Street 1:6609 BEAU CHENE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6500
Practice Address - Country:US
Practice Address - Phone:505-299-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM72149207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM207R00000XMedicaid
NM00011098Medicaid
NM00011098Medicaid
NM$$$$$$$$$PMedicare PIN
NM00011098Medicaid