Provider Demographics
NPI:1083879928
Name:GREEN, HEIDI B (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:B
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:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80001-0668
Mailing Address - Country:US
Mailing Address - Phone:303-422-9438
Mailing Address - Fax:
Practice Address - Street 1:8300 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6005
Practice Address - Country:US
Practice Address - Phone:303-422-9438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41080207L00000X
ORMD166703207L00000X
390200000X
CO50958207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500676017Medicaid
CO63356236Medicaid
CO63356236Medicaid
OR500676017Medicaid