Provider Demographics
NPI:1346468840
Name:EDWARD C GREENLEAF
Entity type:Organization
Organization Name:EDWARD C GREENLEAF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREENLEAF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-481-8312
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0014
Mailing Address - Country:US
Mailing Address - Phone:209-475-1111
Mailing Address - Fax:209-475-1119
Practice Address - Street 1:2027 GRAND CANAL BLVD STE 25
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6650
Practice Address - Country:US
Practice Address - Phone:209-475-1111
Practice Address - Fax:209-475-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG514882085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0044200Medicaid
CAGR0044200Medicaid