Healthcare Provider Details

I. General information

NPI: 1932226644
Provider Name (Legal Business Name): MATTHEW JASON GREENHAWT MD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE
AURORA CO
80045-7106
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301088191
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberDR.0055929
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number061080
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number4301088191
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: