Healthcare Provider Details

I. General information

NPI: 1972540730
Provider Name (Legal Business Name): RICHARD MICHAEL GREEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 WASHINGTON ST SUITE 202
SAN DIEGO CA
92103-2209
US

IV. Provider business mailing address

770 WASHINGTON ST SUITE 202
SAN DIEGO CA
92103-2209
US

V. Phone/Fax

Practice location:
  • Phone: 619-291-0777
  • Fax: 619-291-3231
Mailing address:
  • Phone: 619-291-0777
  • Fax: 619-291-3231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE1311
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: