Provider Demographics
NPI:1558300269
Name:GREEN, TODD ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ROBERT
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:212 E CENTRAL AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6291
Practice Address - Country:US
Practice Address - Phone:509-465-3919
Practice Address - Fax:509-468-0705
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027318207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7088974Medicaid
WAG8802026Medicare PIN
WAE67948Medicare UPIN