Provider Demographics
NPI:1821004326
Name:GREEN, MONICA LOPEZ (MD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:LOPEZ
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:PO BOX 285
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-0285
Mailing Address - Country:US
Mailing Address - Phone:734-542-1970
Mailing Address - Fax:248-614-9756
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 314
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-542-1970
Practice Address - Fax:248-614-9756
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076422208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1821004326Medicaid
MIP37730001Medicare PIN
I08446Medicare UPIN
MIP37720001Medicare PIN
MI0P37730001Medicare PIN