Healthcare Provider Details

I. General information

NPI: 1720405665
Provider Name (Legal Business Name): IAN THOMAS GREENWALT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15195 HEATHCOTE BLVD STE 240
HAYMARKET VA
20169-6245
US

IV. Provider business mailing address

PO BOX 748613
ATLANTA GA
30384-8613
US

V. Phone/Fax

Practice location:
  • Phone: 571-284-3460
  • Fax:
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101283801
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD047318
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: