Provider Demographics
NPI:1396097903
Name:DAVID J GREEN, MD
Entity type:Organization
Organization Name:DAVID J GREEN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-291-3732
Mailing Address - Street 1:7000 STATE ROAD 544
Mailing Address - Street 2:STE 7
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-9536
Mailing Address - Country:US
Mailing Address - Phone:863-291-3732
Mailing Address - Fax:863-299-6287
Practice Address - Street 1:7000 STATE ROAD 544
Practice Address - Street 2:STE 7
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-9536
Practice Address - Country:US
Practice Address - Phone:863-291-3732
Practice Address - Fax:863-299-6287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039042900Medicaid
FLD64487Medicare UPIN