Provider Demographics
NPI:1750335428
Name:GREENBAUM, MARK J (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:GREENBAUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1073
Mailing Address - Country:US
Mailing Address - Phone:770-279-2900
Mailing Address - Fax:770-279-0351
Practice Address - Street 1:1835 SAVOY DR STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-1073
Practice Address - Country:US
Practice Address - Phone:770-279-2900
Practice Address - Fax:770-279-0351
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000611213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00412068AMedicaid
GA480020017OtherRR MEDICARE
GA00412068CMedicaid
GAU05277Medicare UPIN
GA00412068CMedicaid
GA48SCBDRMedicare ID - Type UnspecifiedMEDICARE LILBURN OFFICE
GA48SCBDRMedicare PIN
GA1091410001Medicare NSC
GA00412068AMedicaid
GA48SCBNWMedicare ID - Type UnspecifiedBLAIRSVILLE MEDICARE