Provider Demographics
NPI:1336262559
Name:GREEN, CHARLES BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRUCE
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:84 WESTOVER AVE SW
Mailing Address - Street 2:
Mailing Address - City:BOLLING AFB
Mailing Address - State:DC
Mailing Address - Zip Code:20032-7432
Mailing Address - Country:US
Mailing Address - Phone:210-862-7592
Mailing Address - Fax:202-404-7084
Practice Address - Street 1:HQ USAF SG
Practice Address - Street 2:1780 AIR FORCE PENTAGON
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20330-0001
Practice Address - Country:US
Practice Address - Phone:202-767-4766
Practice Address - Fax:202-404-7084
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG48009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine