Provider Demographics
NPI:1053571455
Name:GARY I GREENWALD MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GARY I GREENWALD MD A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:I
Authorized Official - Last Name:GREENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-341-9777
Mailing Address - Street 1:72855 FRED WARING DR STE A6
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-9369
Mailing Address - Country:US
Mailing Address - Phone:760-341-9777
Mailing Address - Fax:760-341-9872
Practice Address - Street 1:72855 FRED WARING DR STE A6
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-9369
Practice Address - Country:US
Practice Address - Phone:760-341-9777
Practice Address - Fax:760-341-9872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49421174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51362Medicare UPIN
CA00G494210Medicare PIN