Provider Demographics
NPI:1669438412
Name:GREEN, RICHARD DEWAR (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DEWAR
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 1:940 E 3RD ST
Mailing Address - Street 2:#102
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3237
Mailing Address - Country:US
Mailing Address - Phone:330-757-7428
Mailing Address - Fax:
Practice Address - Street 1:940 E 3RD ST
Practice Address - Street 2:#102
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3237
Practice Address - Country:US
Practice Address - Phone:330-757-7428
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2373A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYD93622Medicare UPIN