Provider Demographics
NPI:1952401044
Name:GREEN, REGINIQUE L (MD)
Entity type:Individual
Prefix:MRS
First Name:REGINIQUE
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8500
Mailing Address - Fax:901-260-8598
Practice Address - Street 1:5366 MENDENHALL MALL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4505
Practice Address - Country:US
Practice Address - Phone:901-701-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-74642207Q00000X
TN48371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2104967Medicaid
OH0863362Medicare ID - Type Unspecified
OH2104967Medicaid
OH4204366Medicare PIN