Provider Demographics
NPI:1629003538
Name:GREEN, PRESTON T (MD)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:T
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13575 NW 1ST LN STE 20
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-3735
Mailing Address - Country:US
Mailing Address - Phone:352-332-5755
Mailing Address - Fax:855-964-1157
Practice Address - Street 1:350 NW 76TH DR
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1593
Practice Address - Country:US
Practice Address - Phone:352-332-5755
Practice Address - Fax:866-887-9246
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45509207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045242400Medicaid
FL045242400Medicaid
FL08433YMedicare PIN