Provider Demographics
NPI:1194724476
Name:GREEN, TAMARA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:GW MEDICAL FACULTY ASSOCIATES
Practice Address - Street 2:2120 L STREET NW, STE450
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037
Practice Address - Country:US
Practice Address - Phone:202-741-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA075650300207P00000X
VA0101241273207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
12031278OtherCAQH
P00404964Medicare PIN
014268R71Medicare PIN
H87571Medicare UPIN