Provider Demographics
NPI:1619909744
Name:GREEN, KIRBY ARNESTO (MD)
Entity Type:Individual
Prefix:
First Name:KIRBY
Middle Name:ARNESTO
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 1:2290 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2831
Mailing Address - Country:US
Mailing Address - Phone:801-474-0800
Mailing Address - Fax:801-467-1126
Practice Address - Street 1:2290 SOUTH 1300 EAST
Practice Address - Street 2:MEDICAL MARTS
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2831
Practice Address - Country:US
Practice Address - Phone:801-474-0800
Practice Address - Fax:810-467-1126
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014738207P00000X
UT6053966-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT200785958001Medicaid
LA1194841Medicaid
LA4E106Medicare ID - Type Unspecified
LA1194841Medicaid