Provider Demographics
NPI:1497734347
Name:GREEN, JERRY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
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 1:67 AUNT HACK RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-2720
Mailing Address - Country:US
Mailing Address - Phone:203-798-6566
Mailing Address - Fax:203-790-5883
Practice Address - Street 1:67 AUNT HACK RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-2720
Practice Address - Country:US
Practice Address - Phone:203-798-6566
Practice Address - Fax:203-790-5883
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023599174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001235993Medicaid