Healthcare Provider Details

I. General information

NPI: 1316560378
Provider Name (Legal Business Name): GREEN FLASH PHYSICIAN OVERSIGHT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2868 BAYSIDE WALK UNIT C
SAN DIEGO CA
92109-8119
US

IV. Provider business mailing address

198 SUSSEX DR
MANHASSET NY
11030-3737
US

V. Phone/Fax

Practice location:
  • Phone: 917-273-4092
  • Fax:
Mailing address:
  • Phone: 172-734-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH JOHN MOREIRA
Title or Position: PESIDENT
Credential: MD
Phone: 917-273-4092