Provider Demographics
NPI:1386692333
Name:GREEN, LAWRENCE E (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:E
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 1:16060 IDAHO CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687
Mailing Address - Country:US
Mailing Address - Phone:208-467-3368
Mailing Address - Fax:208-467-3360
Practice Address - Street 1:16060 IDAHO CENTER BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-467-3368
Practice Address - Fax:208-467-3360
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-38142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC47823Medicare UPIN
ID1112614Medicare ID - Type Unspecified