Provider Demographics
NPI:1184864563
Name:GREEN, BRANDON C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:C
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 1:3000 N TRIUMPH BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4999
Mailing Address - Country:US
Mailing Address - Phone:801-505-5370
Mailing Address - Fax:
Practice Address - Street 1:3000 N TRIUMPH BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4999
Practice Address - Country:US
Practice Address - Phone:385-345-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9374436-12052084P2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3004771Medicaid