Provider Demographics
NPI:1477679496
Name:GREEN, STEPHEN LLOYD (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LLOYD
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 1:26 TOWN CENTER WAY # 704
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1999
Mailing Address - Country:US
Mailing Address - Phone:757-771-8049
Mailing Address - Fax:757-851-1285
Practice Address - Street 1:2131 S BONITO WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1659
Practice Address - Country:US
Practice Address - Phone:208-489-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028335207RI0200X
IDM-10266208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1013986579OtherNPI CORPORATION
VA006069479Medicaid
VA1477679496OtherNPI INDIVIDUAL
IDM-10266OtherIDAHO LIC
VAC01649Medicare PIN
IDM-10266OtherIDAHO LIC
VA1477679496OtherNPI INDIVIDUAL
VAB10362Medicare UPIN