Provider Demographics
NPI:1588854905
Name:GREEN-CHEATWOOD, TONI M (DO)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:M
Last Name:GREEN-CHEATWOOD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 N NEVADA AVE
Mailing Address - Street 2:SUITE 235
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-5302
Mailing Address - Country:US
Mailing Address - Phone:719-571-8840
Mailing Address - Fax:719-571-8845
Practice Address - Street 1:2312 N NEVADA AVE
Practice Address - Street 2:SUITE 3235
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-5302
Practice Address - Country:US
Practice Address - Phone:719-571-8840
Practice Address - Fax:719-571-8845
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN104264208600000X
MN52232208600000X
CO48792208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN020002692Medicare PIN