Provider Demographics
NPI:1063410421
Name:GREENBERG, TODD (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:GREENBERG
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-482-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM07392085R0202X
CO00531672085R0202X
WAMD000424132085R0202X
AZ315552085R0202X
KY383412085R0202X
OH35-0778452085R0202X, 2085R0202X
ORMD253832085R0202X, 2085R0202X
MEMD245732085R0202X
NV112002085R0202X
NH124252085R0202X
NMTM2004-05962085R0202X
NY229115-12085R0202X
OH350778452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2551822Medicaid
ME1063410421Medicaid
WA1063410421Medicaid
NH20002179Medicaid