Provider Demographics
NPI:1063662310
Name:W MICHAEL GREEN, MD INC
Entity Type:Organization
Organization Name:W MICHAEL GREEN, MD INC
Other - Org Name:WILLAM M GREEN, MD INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-482-6233
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93011-0986
Mailing Address - Country:US
Mailing Address - Phone:805-482-6233
Mailing Address - Fax:805-389-5883
Practice Address - Street 1:2309 ANTONIO AVE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1414
Practice Address - Country:US
Practice Address - Phone:805-389-5878
Practice Address - Fax:805-389-5883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059650Medicaid
00G19218OtherBLUE SHIELD
00G19218OtherBLUE SHIELD