Provider Demographics
NPI:1306065636
Name:GREENWOOD, NICK CARL (MD)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:CARL
Last Name:GREENWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-1710
Mailing Address - Country:US
Mailing Address - Phone:801-839-4334
Mailing Address - Fax:801-665-6940
Practice Address - Street 1:10 W BROADWAY
Practice Address - Street 2:SUITE 820
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2002
Practice Address - Country:US
Practice Address - Phone:801-716-4284
Practice Address - Fax:801-433-0691
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2012-08-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT6942268-1205207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT45-2648552OtherBUSINESS TAX ID NUMBER