Healthcare Provider Details

I. General information

NPI: 1063446334
Provider Name (Legal Business Name): DEBORAH GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 PARK AVE
FORT LUPTON CO
80621-1929
US

IV. Provider business mailing address

315 PARK AVE
FORT LUPTON CO
80621-1929
US

V. Phone/Fax

Practice location:
  • Phone: 303-857-6111
  • Fax: 303-857-2459
Mailing address:
  • Phone: 303-857-6111
  • Fax: 303-857-2459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24133
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: