Provider Demographics
NPI:1104296094
Name:GREEN, DORET MAE (MSED)
Entity type:Individual
Prefix:MRS
First Name:DORET
Middle Name:MAE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3547 PAULDING AVE
Mailing Address - Street 2:P/H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-1316
Mailing Address - Country:US
Mailing Address - Phone:347-427-1497
Mailing Address - Fax:
Practice Address - Street 1:3547 PAULDING AVE
Practice Address - Street 2:P/H
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-1316
Practice Address - Country:US
Practice Address - Phone:347-427-1497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16510299Medicare PIN