Provider Demographics
NPI:1376565119
Name:GREEN, JEFFREY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
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 1:4150 V ST
Mailing Address - Street 2:PSSB 2100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1460
Mailing Address - Country:US
Mailing Address - Phone:646-942-8290
Mailing Address - Fax:916-762-9040
Practice Address - Street 1:4150 V ST
Practice Address - Street 2:PSSB 2100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1460
Practice Address - Country:US
Practice Address - Phone:646-942-8290
Practice Address - Fax:916-762-9040
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228435207P00000X
CAC54103207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02443341Medicaid
H97053Medicare UPIN
NY02443341Medicaid