Healthcare Provider Details

I. General information

NPI: 1750387973
Provider Name (Legal Business Name): ROBERT S GREENBAUM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date: 01/14/2006
Reactivation Date: 10/10/2007

III. Provider practice location address

1110 ROUTE 55 STE 105
LAGRANGEVILLE NY
12540-5048
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 845-473-0220
  • Fax: 845-473-0140
Mailing address:
  • Phone: 703-847-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number004414
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: