Provider Demographics
NPI:1952644460
Name:GREEN, DERRICK RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:RICHARD
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3200 MACCORKLE AVE SE
Mailing Address - Street 2:DEPT OF PATHOLOGY
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1297
Mailing Address - Country:US
Mailing Address - Phone:304-388-5550
Mailing Address - Fax:304-388-4352
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1297
Practice Address - Country:US
Practice Address - Phone:304-388-5550
Practice Address - Fax:304-388-4352
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2018-09-21
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Provider Licenses
StateLicense IDTaxonomies
WV26706207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology