Provider Demographics
NPI:1740247568
Name:GREENBAUM, MITCHELL GORDON (DO)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:GORDON
Last Name:GREENBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2702 NAVARRE AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3223
Mailing Address - Country:US
Mailing Address - Phone:419-691-8000
Mailing Address - Fax:419-693-0111
Practice Address - Street 1:2702 NAVARRE AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3223
Practice Address - Country:US
Practice Address - Phone:419-691-8000
Practice Address - Fax:419-693-0111
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007744G207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2284675Medicaid
OHGR4065751Medicare ID - Type Unspecified
OHG14264Medicare UPIN