Provider Demographics
NPI:1629040886
Name:GREENE, DONALD RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:RICHARD
Last Name:GREENE
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 1:80 RANDI DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2462
Mailing Address - Country:US
Mailing Address - Phone:203-444-1227
Mailing Address - Fax:203-444-1227
Practice Address - Street 1:80 RANDI DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2462
Practice Address - Country:US
Practice Address - Phone:203-444-1227
Practice Address - Fax:203-444-1227
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018276207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001182765Medicaid
CT001182765Medicaid
CT070000094Medicare ID - Type Unspecified