Provider Demographics
NPI:1720012719
Name:GREENE, DEREK (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86430
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6430
Mailing Address - Country:US
Mailing Address - Phone:605-322-4900
Mailing Address - Fax:605-322-4910
Practice Address - Street 1:1035 S HIGHLINE PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-1000
Practice Address - Country:US
Practice Address - Phone:605-322-2945
Practice Address - Fax:605-322-2926
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD4460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS100745Medicare PIN
SDP00300233Medicare PIN