Provider Demographics
NPI:1518980671
Name:GREEN, DONALD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:JOSEPH
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 1:9250 N 3RD ST STE 3015
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2425
Mailing Address - Country:US
Mailing Address - Phone:602-996-4747
Mailing Address - Fax:602-953-5466
Practice Address - Street 1:13677 W MCDOWELL RD STE 201
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2635
Practice Address - Country:US
Practice Address - Phone:602-996-4747
Practice Address - Fax:602-953-5466
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0061299208600000X
CAC52258174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ37789OtherLICENSE
AZ579138Medicaid
CAC52258OtherMED LICENSE
AZ579138Medicaid
CAC52258OtherMED LICENSE