Provider Demographics
NPI:1316096167
Name:GREEN, AGNES P (MD)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:P
Last Name:GREEN
Suffix:
Gender:F
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 5477
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34674-5477
Mailing Address - Country:US
Mailing Address - Phone:727-868-9563
Mailing Address - Fax:727-869-6909
Practice Address - Street 1:7315 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1158
Practice Address - Country:US
Practice Address - Phone:727-868-9563
Practice Address - Fax:727-869-6909
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92890207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16663OtherBLUE CROSS
FLME92890OtherSTATE LISCENSE
FLC78682Medicare UPIN
FL1663Z-FLMedicare ID - Type Unspecified