Provider Demographics
NPI:1306051073
Name:GREEN, WALTER HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:HOWARD
Last Name:GREEN
Suffix:
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 951
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:VA
Mailing Address - Zip Code:24482-0951
Mailing Address - Country:US
Mailing Address - Phone:540-248-0903
Mailing Address - Fax:
Practice Address - Street 1:16 FORT RIVER RD
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:VA
Practice Address - Zip Code:24482-0951
Practice Address - Country:US
Practice Address - Phone:540-248-0903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101029661OtherVA STATE LICENCE NUMBER