Healthcare Provider Details

I. General information

NPI: 1336262559
Provider Name (Legal Business Name): CHARLES BRUCE GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HQ USAF SG 1780 AIR FORCE PENTAGON
WASHINGTON DC
20330-0001
US

IV. Provider business mailing address

84 WESTOVER AVE SW
BOLLING AFB DC
20032-7432
US

V. Phone/Fax

Practice location:
  • Phone: 202-767-4766
  • Fax: 202-404-7084
Mailing address:
  • Phone: 210-862-7592
  • Fax: 202-404-7084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG48009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: