Provider Demographics
NPI:1972540730
Name:GREEN, RICHARD MICHAEL (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 WASHINGTON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2209
Mailing Address - Country:US
Mailing Address - Phone:619-291-0777
Mailing Address - Fax:619-291-3231
Practice Address - Street 1:770 WASHINGTON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2209
Practice Address - Country:US
Practice Address - Phone:619-291-0777
Practice Address - Fax:619-291-3231
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1311213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOOE13110OtherBLUE SHIELD
CAT10886Medicare UPIN
CAOOOE13110OtherBLUE SHIELD