Provider Demographics
NPI:1336701861
Name:GREEN, OTTAVIA KIMBERLY (MD)
Entity type:Individual
Prefix:
First Name:OTTAVIA
Middle Name:KIMBERLY
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1775 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1143
Practice Address - Country:US
Practice Address - Phone:847-723-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-04
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019022382207L00000X
TXV0407207L00000X
IL036-170213207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0606262218OtherEMPLOYEE ID NUMBER