MEDICARE: JACK GREENBERG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	142512	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790784502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK GREENBERG MD

Provider Business Mailing Address
First Line	:	7139 166TH ST
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11365-3235
Country	:	US
Telephone Number	:	718-380-1173
Fax Number	:	212-685-1452

Provider Business Practice Location Address
First Line	:	30 E 40TH ST RM 607
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-1201
Country	:	US
Telephone Number	:	212-689-1331
Fax Number	:	212-685-1452

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	08/01/2008

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