Healthcare Provider Details

I. General information

NPI: 1629606629
Provider Name (Legal Business Name): CEDRIC GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8793 COMMODITY CIR
ORLANDO FL
32819-9005
US

IV. Provider business mailing address

8793 COMMODITY CIR
ORLANDO FL
32819-9005
US

V. Phone/Fax

Practice location:
  • Phone: 407-351-8200
  • Fax: 407-351-7696
Mailing address:
  • Phone: 407-351-8200
  • Fax: 407-351-7696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME157557
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: