Healthcare Provider Details

I. General information

NPI: 1609882331
Provider Name (Legal Business Name): MARK R GREENBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-5537
  • Fax:
Mailing address:
  • Phone: 831-458-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG48834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: