Provider Demographics
NPI:1265401368
Name:GREENE, EDWARD WILLIAM
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WILLIAM
Last Name:GREENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E PALOMAR ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1800
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:619-397-3380
Practice Address - Street 1:1400 E PALOMAR ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1800
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-397-3380
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A821560Medicaid
CA00A821560Medicaid
CAWA82156AMedicare ID - Type Unspecified