Provider Demographics
NPI:1700041977
Name:GREEN, SANDRA D (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:D
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 1:2505 LARKIN RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3256
Mailing Address - Country:US
Mailing Address - Phone:859-339-8088
Mailing Address - Fax:859-600-1998
Practice Address - Street 1:2505 LARKIN RD STE 103
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3256
Practice Address - Country:US
Practice Address - Phone:859-600-1999
Practice Address - Fax:859-600-1998
Is Sole Proprietor?:No
Enumeration Date:2008-07-27
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41906208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100104650Medicaid