Provider Demographics
NPI:1194909804
Name:DEBORAH GREEN MD PC
Entity type:Organization
Organization Name:DEBORAH GREEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:303-857-6111
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO241330261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO010022980OtherRR PTAN
CO01241330Medicaid
CO01241330Medicaid
COCC1508Medicare PIN