Provider Demographics
NPI:1962498766
Name:GREENBERG, JERRY HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:HOWARD
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:PO BOX 40000
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81658-7520
Mailing Address - Country:US
Mailing Address - Phone:970-476-1110
Mailing Address - Fax:970-470-6648
Practice Address - Street 1:108 S FRONTAGE RD W
Practice Address - Street 2:US BANK BUILDING STE 306
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5053
Practice Address - Country:US
Practice Address - Phone:970-476-1110
Practice Address - Fax:970-470-6648
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23738207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01237387Medicaid
WY1962498766Medicaid
NE10026280600Medicaid
NE10026280800Medicaid
NE10026281000Medicaid
NE10026283100Medicaid
NE1982948089Medicaid
NM03788075Medicaid
NE10026280700Medicaid
NE10026281200Medicaid
KS201070520AMedicaid
NE1982948089Medicaid
NM03788075Medicaid
COC71654Medicare PIN
NE10026281000Medicaid