Provider Demographics
NPI:1851535363
Name:GREEN, JEFFERY TYLER (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:TYLER
Last Name:GREEN
Suffix:
Gender:M
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 480
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0480
Mailing Address - Country:US
Mailing Address - Phone:866-223-6316
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:500 MARTHA JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4668
Practice Address - Country:US
Practice Address - Phone:770-265-6081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71709207ZP0102X
VA0101248582207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology