Provider Demographics
NPI:1972765253
Name:GREEN, BRAD (MD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:
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 1:6835 E CAMELBACK RD UNIT 5005
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3156
Mailing Address - Country:US
Mailing Address - Phone:571-338-1966
Mailing Address - Fax:
Practice Address - Street 1:126 W 82ND ST APT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5584
Practice Address - Country:US
Practice Address - Phone:571-338-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0058207P00000X
OH35.124189207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine