Provider Demographics
NPI:1669665824
Name:GREEN, STEPHANIE ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 VANDERBILT PKWY
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5853
Mailing Address - Country:US
Mailing Address - Phone:631-427-7013
Mailing Address - Fax:
Practice Address - Street 1:488 VANDERBILT PKWY
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5853
Practice Address - Country:US
Practice Address - Phone:631-427-7013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157814-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics