Provider Demographics
NPI:1215935218
Name:GREEN, RICHARD K JR (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 821350
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-0030
Mailing Address - Country:US
Mailing Address - Phone:360-687-5221
Mailing Address - Fax:360-666-0466
Practice Address - Street 1:13712 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2628
Practice Address - Country:US
Practice Address - Phone:360-823-0860
Practice Address - Fax:360-828-1407
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000336302086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8190035Medicaid
G03677Medicare UPIN
WA8190035Medicaid