Provider Demographics
NPI:1740289503
Name:GREEN, STEPHEN ALAN
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:STEPHEN
Other - Middle Name:ALAN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5410 CONNECTICUT AVE NW STE 109
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2819
Mailing Address - Country:US
Mailing Address - Phone:202-363-4117
Mailing Address - Fax:
Practice Address - Street 1:5410 CONNECTICUT AVE NW STE 109
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2819
Practice Address - Country:US
Practice Address - Phone:202-363-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC95882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCE01298Medicare UPIN
DC000R64G64Medicare PIN