Healthcare Provider Details

I. General information

NPI: 1366465460
Provider Name (Legal Business Name): JACK J GREENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 JUAN TABO NE
ALBUQUERQUE NM
87112
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-237-8800
  • Fax: 505-237-8803
Mailing address:
  • Phone: 505-262-7963
  • Fax: 505-232-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81-212
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: