Healthcare Provider Details

I. General information

NPI: 1750335428
Provider Name (Legal Business Name): MARK J. GREENBAUM D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 SAVOY DR STE 200
ATLANTA GA
30341-1073
US

IV. Provider business mailing address

1835 SAVOY DR STE 200
ATLANTA GA
30341-1073
US

V. Phone/Fax

Practice location:
  • Phone: 770-279-2900
  • Fax: 770-279-0351
Mailing address:
  • Phone: 770-279-2900
  • Fax: 770-279-0351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD000611
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: