Provider Demographics
NPI:1699824730
Name:GREEN, DEANNA MAE (MD)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:MAE
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 1:601 5TH ST S
Mailing Address - Street 2:SUITE 708
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4804
Mailing Address - Country:US
Mailing Address - Phone:727-767-4146
Mailing Address - Fax:
Practice Address - Street 1:601 5TH ST S
Practice Address - Street 2:SUITE 708
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4804
Practice Address - Country:US
Practice Address - Phone:727-767-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP19050208000000X
NC2011-009172080P0214X
FLME1239962080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP19050Medicare UPIN