Provider Demographics
NPI:1588960405
Name:GREEN, MATTHEW COLLIN (MD, JD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:COLLIN
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD, JD
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 27128
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-357-1200
Mailing Address - Fax:
Practice Address - Street 1:1157 N 300 W
Practice Address - Street 2:SUTIE 201
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6124
Practice Address - Country:US
Practice Address - Phone:801-357-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT8351448-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program