Provider Demographics
NPI:1215156948
Name:GREEN, TODD RICHARD (DO)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:RICHARD
Last Name:GREEN
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 1:8543 GOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-5241
Mailing Address - Country:US
Mailing Address - Phone:907-347-9686
Mailing Address - Fax:
Practice Address - Street 1:2351 CANARY CT
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1402
Practice Address - Country:US
Practice Address - Phone:907-243-4677
Practice Address - Fax:907-243-4676
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6299207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD5636Medicaid
AK0361450001Medicare NSC
AKMD5636Medicaid