Provider Demographics
NPI:1679832265
Name:GREEN, AMANDA J (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:J
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 1:1411 E 31ST ST
Mailing Address - Street 2:QIC 22134
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1018
Mailing Address - Country:US
Mailing Address - Phone:510-437-4965
Mailing Address - Fax:510-437-5127
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:QIC 22134
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1018
Practice Address - Country:US
Practice Address - Phone:510-437-4965
Practice Address - Fax:510-437-5127
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program