Healthcare Provider Details

I. General information

NPI: 1639161318
Provider Name (Legal Business Name): ERIC GARY GREENBERG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

IV. Provider business mailing address

3963 VIA PALO VERDE LAGO
ALPINE CA
91901-3217
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-1188
  • Fax: 619-445-0579
Mailing address:
  • Phone: 619-445-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A3676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: