Provider Demographics
NPI:1144318916
Name:GREENE, JERRY (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SAWYER RD
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3471
Mailing Address - Country:US
Mailing Address - Phone:781-392-2008
Mailing Address - Fax:781-642-8867
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:C/O MEDICAL SERVICE 111
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132
Practice Address - Country:US
Practice Address - Phone:617-323-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45681207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3060019Medicaid