Healthcare Provider Details

I. General information

NPI: 1104802594
Provider Name (Legal Business Name): DAVID A GREENE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 MONTGOMERY DR
SANTA ROSA CA
95409-8846
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-579-6957
  • Fax: 707-579-6979
Mailing address:
  • Phone: 707-579-6957
  • Fax: 707-579-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20639
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC148038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: