Provider Demographics
NPI:1306901723
Name:GREEN, DOUGLAS O (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:O
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7268
Practice Address - Street 1:700 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5115
Practice Address - Country:US
Practice Address - Phone:360-923-7000
Practice Address - Fax:360-923-7709
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000107492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1324201Medicaid
WA1324201Medicaid
WAA07201Medicare UPIN
WAGAB21617Medicare PIN
WAGAB21614Medicare PIN
WAGAB21613Medicare PIN
WAG8872348Medicare PIN
WAGAB21615Medicare PIN