Provider Demographics
NPI:1821091992
Name:GREEN, SAMUEL E (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3121 S MARYLAND PKWY
Mailing Address - Street 2:STE 512
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2310
Mailing Address - Country:US
Mailing Address - Phone:702-796-7150
Mailing Address - Fax:702-796-9071
Practice Address - Street 1:3150 N TENAYA WAY STE 460
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0463
Practice Address - Country:US
Practice Address - Phone:702-233-1000
Practice Address - Fax:702-233-1001
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV7001207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019596Medicaid
NV002019596Medicaid
NV06WCGXW05Medicare PIN