Provider Demographics
NPI:1396932216
Name:GREEN, MELISSA J (DO)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3617
Mailing Address - Country:US
Mailing Address - Phone:954-271-7180
Mailing Address - Fax:
Practice Address - Street 1:2301 N UNIVERSITY DR
Practice Address - Street 2:SUITE 108
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3617
Practice Address - Country:US
Practice Address - Phone:954-271-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 11024208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002826900Medicaid
FL002826900Medicaid