Provider Demographics
NPI:1437193612
Name:GREEN, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
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 1:601 WEST MAPLE AVE.
Mailing Address - Street 2:SUITE 703
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764
Mailing Address - Country:US
Mailing Address - Phone:479-750-2203
Mailing Address - Fax:479-750-1193
Practice Address - Street 1:601 W MAPLE AVE
Practice Address - Street 2:SUITE 703
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-750-2203
Practice Address - Fax:479-750-1193
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7697207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100078010AMedicaid
MO208228700Medicaid
AR168460000OtherQUAL CHOICE
AR117593001Medicaid
ARC7697OtherAR STATE LICENSE
ARC7697OtherAR STATE LICENSE
OK100078010AMedicaid
AR53872Medicare ID - Type UnspecifiedAR MEDICARE
ARP00124674Medicare ID - Type UnspecifiedRR MEDICARE