Provider Demographics
NPI:1316196520
Name:GREEN, DEBRA (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:GREEN
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:927 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10028
Mailing Address - Country:US
Mailing Address - Phone:212-584-2619
Mailing Address - Fax:646-588-4443
Practice Address - Street 1:927 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10028
Practice Address - Country:US
Practice Address - Phone:212-584-2619
Practice Address - Fax:646-588-4443
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400014184Medicare PIN