Healthcare Provider Details

I. General information

NPI: 1407075294
Provider Name (Legal Business Name): MARK GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 CONCORD AVE
BELMONT MA
02478-4046
US

IV. Provider business mailing address

90 CONCORD AVE
BELMONT MA
02478-4046
US

V. Phone/Fax

Practice location:
  • Phone: 857-598-2808
  • Fax: 857-598-2864
Mailing address:
  • Phone: 857-598-2808
  • Fax: 857-598-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number222713
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number222713
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number222713
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: