Provider Demographics
NPI:1376601393
Name:W MICHAEL GREEN, MD INC
Entity Type:Organization
Organization Name:W MICHAEL GREEN, MD INC
Other - Org Name:WM MICHAEL GREEN MD INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-988-2644
Mailing Address - Street 1:PO BOX 25420
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93002-2277
Mailing Address - Country:US
Mailing Address - Phone:805-650-5910
Mailing Address - Fax:805-650-5972
Practice Address - Street 1:1600 N ROSE AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3722
Practice Address - Country:US
Practice Address - Phone:805-988-2644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ42071ZOtherBLUE SHIELD
CAGR0059650Medicaid
CAZZZ42071ZOtherBLUE SHIELD
CAHW8241AMedicare PIN