Provider Demographics
NPI:1922174374
Name:GREENBERG, PAUL JAY (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JAY
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9291 LAUREL GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2969
Mailing Address - Country:US
Mailing Address - Phone:804-730-7089
Mailing Address - Fax:804-730-8987
Practice Address - Street 1:9291 LAUREL GROVE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2969
Practice Address - Country:US
Practice Address - Phone:804-730-7089
Practice Address - Fax:804-730-8987
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000793213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009332219Medicaid
VA195483OtherANTHEM
VA480000238Medicare ID - Type Unspecified
VAT21336Medicare UPIN