Healthcare Provider Details

I. General information

NPI: 1629040886
Provider Name (Legal Business Name): DONALD RICHARD GREENE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 RANDI DR
MADISON CT
06443-2462
US

IV. Provider business mailing address

80 RANDI DR
MADISON CT
06443-2462
US

V. Phone/Fax

Practice location:
  • Phone: 203-444-1227
  • Fax: 203-444-1227
Mailing address:
  • Phone: 203-444-1227
  • Fax: 203-444-1227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number018276
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: