Provider Demographics
NPI:1649244419
Name:GREEN, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:367 CEDAR ST
Mailing Address - Street 2:ESH A-201
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3222
Mailing Address - Country:US
Mailing Address - Phone:203-785-3327
Mailing Address - Fax:203-737-7630
Practice Address - Street 1:1450 CHAPEL STREET
Practice Address - Street 2:FAMILY HEALTH CENTER
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001395492Medicaid
F31640Medicare UPIN
CT110008085Medicare ID - Type Unspecified