Provider Demographics
NPI:1457627606
Name:GREENE, HEATHER MIRANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MIRANDA
Last Name:GREENE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 PARKLAND CIR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3321
Mailing Address - Country:US
Mailing Address - Phone:505-205-3581
Mailing Address - Fax:
Practice Address - Street 1:1217 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1529
Practice Address - Country:US
Practice Address - Phone:505-766-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-31
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0118207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine