Provider Demographics
NPI:1073581344
Name:GREEN, LAWRENCE J (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:J
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 1:9601 BLACKWELL RD STE 260
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6487
Mailing Address - Country:US
Mailing Address - Phone:301-610-0663
Mailing Address - Fax:301-610-5420
Practice Address - Street 1:9601 BLACKWELL RD STE 260
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6487
Practice Address - Country:US
Practice Address - Phone:301-610-0663
Practice Address - Fax:301-610-5420
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD50346207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G21071Medicare UPIN
MD667545Medicare PIN