Provider Demographics
NPI:1497843312
Name:GREEN, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:710 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3726
Mailing Address - Country:US
Mailing Address - Phone:212-305-8455
Mailing Address - Fax:212-305-8530
Practice Address - Street 1:710 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3726
Practice Address - Country:US
Practice Address - Phone:212-305-8455
Practice Address - Fax:212-305-8530
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1240762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC08615Medicare UPIN
NY331321Medicare ID - Type Unspecified