Provider Demographics
NPI:1235123191
Name:GREEN, WAVERLY SYNDOR III (MD)
Entity Type:Individual
Prefix:DR
First Name:WAVERLY
Middle Name:SYNDOR
Last Name:GREEN
Suffix:III
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 1:580 SAINT JOHNSBURY RD
Mailing Address - Street 2:SUITE 25
Mailing Address - City:LITTLETON
Mailing Address - State:NH
Mailing Address - Zip Code:03561-3437
Mailing Address - Country:US
Mailing Address - Phone:603-259-7780
Mailing Address - Fax:603-444-2769
Practice Address - Street 1:580 SAINT JOHNSBURY RD
Practice Address - Street 2:SUITE 25
Practice Address - City:LITTLETON
Practice Address - State:NH
Practice Address - Zip Code:03561-3437
Practice Address - Country:US
Practice Address - Phone:603-259-7780
Practice Address - Fax:603-444-2769
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300133207RP1001X
NH15701207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC29211OtherBCBS-IND.
NC7937060Medicaid
NCE06853Medicare UPIN
NC2197993BMedicare PIN