Provider Demographics
NPI:1225249055
Name:GREEN, JEREMY BLAIR (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:BLAIR
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4425 PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1837
Mailing Address - Country:US
Mailing Address - Phone:305-443-6606
Mailing Address - Fax:305-443-4890
Practice Address - Street 1:4425 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1837
Practice Address - Country:US
Practice Address - Phone:305-443-6606
Practice Address - Fax:305-443-4890
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME107541207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology