Healthcare Provider Details

I. General information

NPI: 1619908829
Provider Name (Legal Business Name): BRUCE GREENWALD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 S HILL RD
VENTURA CA
93003-8400
US

IV. Provider business mailing address

2590 E MAIN ST
VENTURA CA
93003-2619
US

V. Phone/Fax

Practice location:
  • Phone: 805-477-6464
  • Fax: 805-477-6498
Mailing address:
  • Phone: 805-477-6464
  • Fax: 805-477-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG48134
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: