Provider Demographics
NPI:1316045644
Name:GREENE, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:GREENE
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 1:3700 JOSEPH SIEWICK DRIVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1738
Mailing Address - Country:US
Mailing Address - Phone:703-758-7500
Mailing Address - Fax:703-758-8316
Practice Address - Street 1:3700 JOSEPH SIEWICK DRIVE
Practice Address - Street 2:SUITE 203
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1738
Practice Address - Country:US
Practice Address - Phone:703-758-7500
Practice Address - Fax:703-758-8316
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040924207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101040924OtherVIRGINIA LICENSE
419556Medicare ID - Type Unspecified
62723Medicare UPIN