Provider Demographics
NPI:1215989199
Name:GREEN, IVAN R (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:R
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-853-2716
Mailing Address - Fax:508-856-9025
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-853-2716
Practice Address - Fax:508-856-9025
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-02-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA369462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B98839Medicare UPIN