Provider Demographics
NPI:1962516310
Name:GREENWALD, DAVID LANCE (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LANCE
Last Name:GREENWALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:100 WHETSTONE PL
Practice Address - Street 2:STE 310
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5774
Practice Address - Country:US
Practice Address - Phone:904-217-7450
Practice Address - Fax:904-217-7483
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65494207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43658OtherBCBS
FL002101800Medicaid
FLP00956145OtherRR MEDICARE
FL43658OtherBCBS