Healthcare Provider Details

I. General information

NPI: 1386739605
Provider Name (Legal Business Name): DOUGLAS WILLIAM GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SOTOYOME ST
SANTA ROSA CA
95405-4823
US

IV. Provider business mailing address

121 SOTOYOME ST
SANTA ROSA CA
95405-4823
US

V. Phone/Fax

Practice location:
  • Phone: 707-549-3141
  • Fax: 707-546-7351
Mailing address:
  • Phone: 707-549-3141
  • Fax: 707-546-7351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA90305
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA90305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: