Provider Demographics
NPI:1033374335
Name:GREEN, MARTIN (DC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 NE 124TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5523
Mailing Address - Country:US
Mailing Address - Phone:305-891-4114
Mailing Address - Fax:
Practice Address - Street 1:640 NE 124TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5523
Practice Address - Country:US
Practice Address - Phone:305-891-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 2711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT99412Medicare UPIN