Basic Information
| Provider Information | |||||||||
| NPI: | 1376529867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENBERG | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | KING CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939303432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313857169 | ||||||||
| FaxNumber: | 8313855940 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | KING CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939303432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313857169 | ||||||||
| FaxNumber: | 8313855940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G32040 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | G320401 | 05 | CA | MEDICAID |