Provider Demographics
NPI:1750387973
Name:GREENBAUM, ROBERT S (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:GREENBAUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:1110 ROUTE 55 STE 105
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5048
Practice Address - Country:US
Practice Address - Phone:845-473-0220
Practice Address - Fax:845-473-0140
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2024-12-13
Deactivation Date:2006-01-14
Deactivation Code:
Reactivation Date:2007-10-10
Provider Licenses
StateLicense IDTaxonomies
NY004414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY597014OtherMVP HEALTH PLAN
NY0007187044OtherAETNA
NY10032470OtherCDPHP
P2790040OtherOXFORD HEALTH INSURANCE
NY02144998Medicaid
NY597014OtherMVP HEALTH PLAN
P2790040OtherOXFORD HEALTH INSURANCE