Healthcare Provider Details

I. General information

NPI: 1215156948
Provider Name (Legal Business Name): TODD RICHARD GREEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 CANARY CT
ANCHORAGE AK
99515-1402
US

IV. Provider business mailing address

8543 GOLDEN ST
ANCHORAGE AK
99502-5241
US

V. Phone/Fax

Practice location:
  • Phone: 907-243-4677
  • Fax: 907-243-4676
Mailing address:
  • Phone: 907-347-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6299
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMD5636
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: