Provider Demographics
NPI:1063446334
Name:GREEN, DEBORAH (MD)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1929
Mailing Address - Country:US
Mailing Address - Phone:303-857-6111
Mailing Address - Fax:303-857-2459
Practice Address - Street 1:315 PARK AVE
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1929
Practice Address - Country:US
Practice Address - Phone:303-857-6111
Practice Address - Fax:303-857-2459
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO010022980OtherRR PTAN
CO01241330Medicaid
COCC1518Medicare PIN
COD24397Medicare UPIN