Provider Demographics
NPI:1992711600
Name:GREEN, WILLIAM FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FREDERICK
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:FREDERICK
Other - Last Name:GREEN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2211 LOMAS BLVD NE
Mailing Address - Street 2:MSC10 5590
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-2345
Mailing Address - Fax:
Practice Address - Street 1:1505 STANFORD DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3727
Practice Address - Country:US
Practice Address - Phone:505-255-1108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-56208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS5672Medicaid
NMH54822Medicare UPIN