Provider Demographics
NPI:1720174873
Name:GREEN, KIMBERLY J (DO)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 CAMBRIDGE SQ
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1875
Mailing Address - Country:US
Mailing Address - Phone:770-754-9880
Mailing Address - Fax:770-754-9881
Practice Address - Street 1:1090 CAMBRIDGE SQ
Practice Address - Street 2:SUITE A
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1875
Practice Address - Country:US
Practice Address - Phone:770-754-9880
Practice Address - Fax:770-754-9881
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58478208D00000X
IN2002456A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01BCHWHMedicare PIN