Healthcare Provider Details

I. General information

NPI: 1720144975
Provider Name (Legal Business Name): MARK GREENWALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

777 BANNOCK ST
DENVER CO
80204-4597
US

V. Phone/Fax

Practice location:
  • Phone: 303-436-4949
  • Fax: 303-602-4560
Mailing address:
  • Phone: 303-436-4949
  • Fax: 303-602-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036055837
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberDR.0070955
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: