Provider Demographics
NPI:1063665719
Name:GREEN, MICHAEL MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:81 N MARIO CAPECCHI DR
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1125
Mailing Address - Country:US
Mailing Address - Phone:801-213-7737
Mailing Address - Fax:801-587-7539
Practice Address - Street 1:81 N MARIO CAPECCHI DR
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1125
Practice Address - Country:US
Practice Address - Phone:801-213-7737
Practice Address - Fax:801-587-7539
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2021-12-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXBP10031712208100000X
MO20110178202081P0010X
UT8728465-12042081P0301X, 2081P0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program