Provider Demographics
NPI:1861424418
Name:GREENSTADT, MARC (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:GREENSTADT
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 1:18350 ROSCOE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4109
Mailing Address - Country:US
Mailing Address - Phone:818-717-3021
Mailing Address - Fax:818-717-3028
Practice Address - Street 1:18350 ROSCOE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4109
Practice Address - Country:US
Practice Address - Phone:818-717-3021
Practice Address - Fax:818-717-3028
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G351410Medicaid
CA00G351410Medicaid