Provider Demographics
NPI:1265537187
Name:GREEN, MICHAEL SEAN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SEAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SEAN
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 12366
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-0366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16001 QUARRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3359
Practice Address - Country:US
Practice Address - Phone:503-635-1604
Practice Address - Fax:503-635-6659
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD183722084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR081799Medicaid
OR081799Medicaid