Provider Demographics
NPI:1356307334
Name:GREEN, KEVIN B (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
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 902
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06504-0902
Mailing Address - Country:US
Mailing Address - Phone:203-397-8000
Mailing Address - Fax:203-389-1540
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-444-5100
Practice Address - Fax:860-444-3709
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049143207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008022648Medicaid
CT008022648Medicaid
VAP00320918Medicare PIN
VA008679K85Medicare ID - Type Unspecified