Provider Demographics
NPI:1295796142
Name:GREEN, ROBERT D (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 POLO PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1423
Mailing Address - Country:US
Mailing Address - Phone:804-378-6035
Mailing Address - Fax:804-560-9360
Practice Address - Street 1:2900 POLO PKWY STE 101
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-1423
Practice Address - Country:US
Practice Address - Phone:804-378-6035
Practice Address - Fax:804-560-9360
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556304111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA183417OtherANTHEM BCBS
298933OtherANTHEM- ACTIVE CHIRO
VA7993638OtherAETNA
V03798Medicare UPIN
VA7993638OtherAETNA
VA00X530A01Medicare PIN