Provider Demographics
NPI:1346602927
Name:GREEN, KEVIN ROY (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROY
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:PO BOX 9218
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-9218
Mailing Address - Country:US
Mailing Address - Phone:612-637-2575
Mailing Address - Fax:
Practice Address - Street 1:1004 S OLD DIXIE HWY STE 202
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7200
Practice Address - Country:US
Practice Address - Phone:561-745-6950
Practice Address - Fax:561-263-7260
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140303207R00000X, 207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program