Provider Demographics
NPI:1629210992
Name:GREEN, MATTHEW REED (MD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:REED
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 1:2546 E 2ND ST.
Mailing Address - Street 2:#400
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609
Mailing Address - Country:US
Mailing Address - Phone:307-234-0003
Mailing Address - Fax:
Practice Address - Street 1:2546 E 2ND ST.
Practice Address - Street 2:#400
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609
Practice Address - Country:US
Practice Address - Phone:307-234-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WY8877A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program