Healthcare Provider Details

I. General information

NPI: 1497246649
Provider Name (Legal Business Name): JEFFREY EMANUEL GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 TANAGER LN
POTOMAC MD
20854-6316
US

IV. Provider business mailing address

10600 TANAGER LN
POTOMAC MD
20854-6316
US

V. Phone/Fax

Practice location:
  • Phone: 301-332-0467
  • Fax:
Mailing address:
  • Phone: 301-332-0467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberD0031283
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0031283
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: