Provider Demographics
NPI:1295796951
Name:GREEN, GORDON MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:MARTIN
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 1:1020 CORN TASSEL TRL
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-5606
Mailing Address - Country:US
Mailing Address - Phone:276-666-4474
Mailing Address - Fax:
Practice Address - Street 1:295 COMMONWEALTH BLVD W
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1820
Practice Address - Country:US
Practice Address - Phone:276-638-2311
Practice Address - Fax:276-638-3537
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010362661Medicaid
VAG25569Medicare UPIN
VA015231C63Medicare PIN