Provider Demographics
NPI:1154767846
Name:GREENE, RANDALL B (DO)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:B
Last Name:GREENE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 TRISMEN TERRACE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789
Mailing Address - Country:US
Mailing Address - Phone:321-277-5445
Mailing Address - Fax:407-628-6456
Practice Address - Street 1:201 TRISMEN TERRACE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789
Practice Address - Country:US
Practice Address - Phone:321-277-5445
Practice Address - Fax:407-628-6456
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS40372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAG8892879OtherDEA REGISTRATION #