Provider Demographics
NPI:1689752404
Name:GREEN, MICHELE S (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:S
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 1:156 E 79TH ST APT 1B
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0570
Mailing Address - Country:US
Mailing Address - Phone:212-535-3088
Mailing Address - Fax:
Practice Address - Street 1:156 E 79TH ST APT 1B
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0570
Practice Address - Country:US
Practice Address - Phone:212-535-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191657207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
228541Medicare ID - Type Unspecified
G16123Medicare UPIN