Healthcare Provider Details

I. General information

NPI: 1578950390
Provider Name (Legal Business Name): PATRICIA GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 BENNING RD NE
WASHINGTON DC
20019-4555
US

IV. Provider business mailing address

4414 BENNING RD NE
WASHINGTON DC
20019-4555
US

V. Phone/Fax

Practice location:
  • Phone: 202-388-7758
  • Fax:
Mailing address:
  • Phone: 202-469-4699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA10341200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD048038
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: