Provider Demographics
NPI:1013135565
Name:GREENWALD, HERBERT SAM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:SAM
Last Name:GREENWALD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26700
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6700
Mailing Address - Country:US
Mailing Address - Phone:478-474-7430
Mailing Address - Fax:478-474-6247
Practice Address - Street 1:5067 WELLINGTON DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4429
Practice Address - Country:US
Practice Address - Phone:478-474-7430
Practice Address - Fax:478-474-6247
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA011346207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAG5253199OtherNARCOTICS LICENSE
GA011346OtherMEDICAL LICENSE
GA011346OtherMEDICAL LICENSE