Healthcare Provider Details

I. General information

NPI: 1033192885
Provider Name (Legal Business Name): DAVID W. GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 STATE ST
NEWBURYPORT MA
01950-6621
US

IV. Provider business mailing address

143 STATE ST
NEWBURYPORT MA
01950-6621
US

V. Phone/Fax

Practice location:
  • Phone: 978-462-2890
  • Fax: 978-462-2890
Mailing address:
  • Phone: 978-462-2890
  • Fax: 978-462-2890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number47625
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: