Provider Demographics
NPI:1720014608
Name:EDREIRA-GREEN, GLORIA C (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:C
Last Name:EDREIRA-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 1:943 HUALAPAI WAY
Mailing Address - Street 2:
Mailing Address - City:PEACH SPRINGS
Mailing Address - State:AZ
Mailing Address - Zip Code:86434
Mailing Address - Country:US
Mailing Address - Phone:928-769-2900
Mailing Address - Fax:
Practice Address - Street 1:943 HUALAPAI WAY
Practice Address - Street 2:
Practice Address - City:PEACH SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86434
Practice Address - Country:US
Practice Address - Phone:928-769-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06551000207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8887501Medicaid
NJ061953Medicare ID - Type Unspecified
NJ8887501Medicaid