Provider Demographics
NPI:1205061447
Name:JEFFREY MARK GREENBERG MD PA
Entity type:Organization
Organization Name:JEFFREY MARK GREENBERG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GREENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-979-5153
Mailing Address - Street 1:PO BOX 494240
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-4240
Mailing Address - Country:US
Mailing Address - Phone:941-979-5153
Mailing Address - Fax:
Practice Address - Street 1:2811 TAMIAMI TRL
Practice Address - Street 2:SUITE I
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5173
Practice Address - Country:US
Practice Address - Phone:941-979-5153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104409207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCD301BMedicare PIN