Provider Demographics
NPI:1841299633
Name:GREENBERG, BRUCE W (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
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 1:1554 DUTCH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4522
Mailing Address - Country:US
Mailing Address - Phone:516-825-7252
Mailing Address - Fax:516-825-4753
Practice Address - Street 1:1554 DUTCH BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4522
Practice Address - Country:US
Practice Address - Phone:516-825-7252
Practice Address - Fax:516-825-4753
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01247790Medicaid
NY95F331Medicare PIN
E90473Medicare UPIN