Provider Demographics
NPI:1912402801
Name:GREEN, AUSTIN REID (MD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:REID
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 1:208 EDITH BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3581
Mailing Address - Country:US
Mailing Address - Phone:574-309-1023
Mailing Address - Fax:
Practice Address - Street 1:635 BARNHILL DR BLDG A-128
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5126
Practice Address - Country:US
Practice Address - Phone:317-274-4806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01093181A207ZP0102X, 207ZD0900X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program