Provider Demographics
NPI:1407023369
Name:GREEN, MICHELLE GOLDBERG (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GOLDBERG
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:KRISTAL
Other - Last Name:GOLDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:115 E 61ST ST
Mailing Address - Street 2:SUITE 7E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-8183
Mailing Address - Country:US
Mailing Address - Phone:212-317-1100
Mailing Address - Fax:212-317-1391
Practice Address - Street 1:115 E 61ST ST
Practice Address - Street 2:SUITE 7E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8183
Practice Address - Country:US
Practice Address - Phone:212-317-1100
Practice Address - Fax:212-317-1391
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254117207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A400068399Medicare PIN