Healthcare Provider Details

I. General information

NPI: 1598922866
Provider Name (Legal Business Name): AYODELE GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ROUTE 46 W BLDG F
MOUNTAIN LAKES NJ
07046-1668
US

IV. Provider business mailing address

PO BOX 282
MOUNTAIN LAKES NJ
07046-0282
US

V. Phone/Fax

Practice location:
  • Phone: 973-722-0483
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number25MA10430000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number237047
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25MA10430000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: